Reconstructive Step Research Articles

Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study

ObjectiveTo assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer.MethodsThis was a multicenter, retrospective, controlled study....

Laparoscopic Millin with Full Vesicourethral Anastomosis—Implications for Hematuria and Ejaculation

Clinical History: A 64-year-old man presented lower urinary tract symptoms (LUTS) and two acute urinary retentions in 6 months, despite having taken dutasteride and tamsulosin. Physical Examination: Digital rectal examination: unsuspicious, enlarged, and inflamed prostate. Diagnosis: Ultrasonography 90 mL prostate, Qmax 3 mL/sec, total prostate-specific antigen (PSA) 5.7 ng/mL, and PSA density 0.06 ng/mL2. Benign prostatic obstruction was diagnosed. Intervention: We started a standard four-port extraperitoneal transcapsular laparoscopic simple prostatectomy (LSP). After adenoma complete removal, including middle lobe and prostatic urethra, we performed our modification, adding a reconstructive step to the standard procedure: a continuous vesicourethral anastomosis (VUA), using a 5/8 circle needle, with 3-0 absorbable unidirectional barbed suture. Prostatic capsule was closed traditionally. Follow-Up/Outcomes: Hematuria was residual and continuous bladder irrigation (CBI) was removed on day 1. Urethral catheter (UC) was maintained for 6 days. At seven weeks, patient presented without LUTS and with antegrade ejaculation, the status that he maintains after 12 months, without complications. Therefore, simply adding VUA to LSP, we may achieve the absence of significant postoperative LUTS and hematuria, obviating CBI need, and even preserve antegrade ejaculation. The success of this case reflects this technique worldwide feasibility, even in large prostates with middle lobe and impossible urethra preservation, without requiring extraordinary material and allying surgical steps already known. We are routinely performing and attempting to improve this technique. We aim to eliminate CBI and remove UC sooner, and to evaluate the possible risk of VUA stricture, or treatment implications on eventual future prostate cancer, in a starting randomized study, but we believe that its advantages may outweigh the risks. No competing financial interests exist. Runtime of video: 5 mins 0 secs Authors' Contributions: All authors contributed to the design of the study, are accountable for all aspects of the study, and have approved the final article for publication. Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Prior abstract presentations: UROtech22, May 26–28, 2022, Istanbul, Turkey; 6th AIM ACELAS—Algerian Community of Endourology and Laparoscopic Surgery—INTERNATIONAL MEETING, September 29–October 1, 2022, Algiers, Algeria.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Following the phase transitions of iron in 3D with X-ray tomography and diffraction under extreme conditions

Transformations of iron at high pressure and temperature has significant implications in Fe-based materials technology as well as in planetary science due to its prominent presence in terrestrial planet cores. However, a detailed understanding of processes involved in the high temperature α-Fe ↔ γ-Fe and the high pressure α-Fe ↔ ϵ-Fe transformations is still lacking. In this study, we monitored in situ the orientations and mobility of the interfaces of coexistence of parent and daughter phases of iron upon transitions around the α−γ−ϵ triple point. We show that in α-Fe ↔ ϵ-Fe transitions, a displacive mechanism induces typical martensitic microstructures, but is followed by a second likely reconstructive step which transforms most of the sample. Under similar pressure, temperature and heating rate conditions, α-Fe ↔ γ-Fe transformations appear to be purely reconstructive. This work provides for the first time a complete 3D microstructural in situ characterization of iron structural transitions under extreme conditions that clarifies their fundamental mechanisms.

Abdominal Wall Reconstruction with the Two-step Technique: Procedure Optimization and Three-year Follow-up in 26 Surgeries.

Background:Complex or recurrent abdominal wall defects may be the result of trauma, infection, tumor resection, or a previous failed attempt at closure, among other causes. This article describes a new surgical technique that better addresses these defects and provides safety and efficacy data from 26 consecutive surgeries with a 3-year follow-up.Methods:Prospective study in 18 men and 8 women with serious abdominal wall defects, who were surgically operated on using the two-step technique, which includes a first regenerative and closure step using a vacuum device (vacuum-assisted closure), and a second reconstructive step that does not require the use of any type of surgical mesh. The safety and efficacy results were evaluated through clinical examinations and questionnaires. The severity of patient-experienced pain and both patient and surgeon satisfaction were quantified on a scale from 0 to 10 points. The statistical calculations focused on the mean (m), range (r), and percentage (%).Results:The mean complete surface area of the abdominal wall defects was 250.2 cm2 (r = 78–770 cm2). The patient and surgeon satisfaction rates at the time of hospital discharge were m = 9.0 (r = 3–10) and m = 9.4 (r = 8–10), respectively. After 3 years, these rates were m = 7.2 (r = 3–10) and m = 9.8 (r = 9–10), respectively. No relevant complications were observed in any stage of the study and no recurrence was observed 3 years later. The main complaint of patients was the presence of hypertrophic scars from the surgical wound (57% of cases).Conclusion:The two-step technique is an excellent alternative for the repair of complete abdominal wall defects of up to 800 cm2 because it allows serious complications to be avoided, prevents recurrences, and shows high rates of both patient and surgeon satisfaction.

Dual plane breast implant reconstruction in large sized breasts: How to maximise the result following first stage total submuscular expansion

IntroductionWomen who were good candidates for a skin reducing mastectomy, but were instead treated with a skin-sparing mastectomy and reconstruction with expanders, show discrepancy of volume and form between the healthy breast (voluminous and ptotic) and the expanded mastectomy envelope and muscle, which has a smaller size as well as excessive amount of skin at the lower pole. MethodsFrom January 2014 to March 2015, we recruited 18 women with breasts of medium to large volume and with moderate to severe ptosis, already treated at a different centre with a one-side mastectomy and reconstruction by means of an expander. These women were treated at our unit for the second reconstructive step with a dual plane technique and a contralateral reduction/mastopexy. ResultsThe minimum duration of follow-up was 2 years (range 24–30 months). The average volume of the implants was 613 g. The reconstructive outcome at the final follow-up (at least 24 months) was judged by the specialist as excellent in 5 cases, very good in 10 cases and good in 3 cases. Breast Q average score was 87.08. DiscussionThe disinsertion of the expanded muscle dome and the use of a dual plane technique for the placement of the definitive implant provide a solution to the skin-volume mismatch problem. The subcutaneous placement of the implant at the level of the lower pole extends the excessive amount of skin and gives the reconstructed breast fullness and natural ptosis. Further validation of our results is needed.

Frontoparietal Cranial Loss of Substance: CT Study and Microsurgical Reconstruction with Radial Flap.

Introduction: Plastic Surgery has been largely evolved during last decades, although its fundamental reconstructive techniques have been adapted to a wide range of clinical needs. In this scenario, microsurgery has an increasingly important role, both for experienced surgeons, both for new learners, and the factor which makes more successful a reconstruction is the preoperative clinical and imaging-based evaluation. A 25-year old woman presented to plastic surgery division 3 weeks after she had underwent a neurosurgical intervention for aneurism complicated by rupture of the same and consequent hematoma (Figure 1). This preliminary CT study presents a wide loss of substance on the lateral right cranial vault (Figure 2). The evaluation was conducted with and without injectable iodinated contrast medium agent and has allowed a thin-layer detailed vision of the structures of the posterior fossa and supratentorial regions. Images revealed on the right side a wide hyperdense area characterised by “biconvex lens” fashion with small air bubbles in its context and relative hematoma: the blood is likely to be in communication with a further accumulation positioned in subcutaneous soft tissues, on the right, above the bone operculum. Even in this place small air bubbles are detectable. Images also offer the vision of a hemispherical right area, referable to parenchymal damage in stabilization, compressive effect on the right parenchyma and the ipsilateral ventricular system and edema of the soft tissues of the cheek region of the right. Reconstruction: A radial forearm flap was harvested in standard fashion to realize a microsurgical reconstruction (Figure 3). The forearm flap’s area was adapted to cover the defect, microvascular anastomosis was then performed in standard fashion and Doppler was applied for both intraoperative and postoperative monitoring. Pictures show the preoperative markings and the immediate postoperative result. Conclusions: The preoperative evaluation for a reconstructive step results precious and precious both in election and in emergency. This case presents the complexity brought by a frontoparietal cranial loss of substance and its relative preliminary CT study.

The use of the reversed facial flap in midface reconstruction following advanced sinonasal malignancies

The objectives of the study: Advanced or recurrent sinonasal malignancies sometimes need, besides an ablative step, a reconstructive step. If this occurs, the reconstructive step may require advanced knowledge of reconstructive surgery because of the complex remnant defects after ablation. The methodology: The authors present a surgical reconstructive solution that can be used in cases of advanced sino nasal tumors which associate the destruction of the malar region. This requires a midfacial flap which will provide a solid support for the paramedial forehead flap. Conclusions: The use of the reversed midfacial flap is an original method that can provide a good mechanical support for any reconstructive flap in the midfacial region. Keyw ords: sino nasal malignancies, reconstruction, flap

Modified gluteal fold advancement V-Y flap for vulvar reconstruction after surgery for vulvar malignancies

ObjectiveThe aim of the study is to assess the feasibility and complications of the modified V-Y advancement gluteal flap in the vulvo-perineal reconstruction among women operated for vulvar malignancies. MethodsFrom December 2008 to April 2012 women who underwent radical surgery for invasive vulvar cancer were considered for the study. Patients after demolitive procedure were submitted to reconstructive step (Group A) consisting of bilateral or monolateral V-Y advancement fascio-cutaneous flap, from gluteal fold. Surgical results were compared to those of a historical group of patients (Group B) with the same characteristics but not submitted to the reconstructive step. ResultsTwenty-nine patients were considered for the study and submitted to radical surgery followed by V-Y flap. Surgical results were compared to those of 78 patients submitted to demolitive surgery only. There were no differences in terms of clinical characteristics between the two groups. The average length of hospital stay was 7 and 10days, respectively for Groups A and B (P=0.0067). Mean operating time was higher in Group A, 210 vs 120min (P<0.00001). Among women with tumor size larger than 4cm (27 Group A, 30 Group B), Group A had lower complication rate (dehiscence 11% vs 40%; P=0.0172). ConclusionsModified gluteal fold advancement V-Y flap is a safe and simple procedure and can be harvested in a single surgery session. It could be able to reduce hospital stay and in patients with large loss of substance could reduce rate of complications.

Reconstructive management of degloving trauma of male external genitalia using dermal regeneration template: A case report

Traumatic injuries of male external genitalia are rare and not usually life threatening; however, they can have psychological repercussions. The reconstructive management of these lesions is challenging and articulated. We report the case of a 38-year-old farmer suffering from a degloving wound on the external genitalia. The first reconstructive step used to treat the wound was the incorporation of a dermal regeneration template (Integra(®)) and accordingly partial-thickness skin grafts and local flaps. The follow-up 16 months after the first treatment was satisfying; sexual function had been restored.

DIGITAL RECONSTRUCTION OF AN ARCHAEOLOGICAL SITE BASED ON THE INTEGRATION OF 3D DATA AND HISTORICAL SOURCES

Abstract. The methodology proposed in this paper in based on an integrated approach for creating a 3D digital reconstruction of an archaeological site, using extensively the 3D documentation of the site in its current state, followed by an iterative interaction between archaeologists and digital modelers, leading to a progressive refinement of the reconstructive hypotheses. The starting point of the method is the reality-based model, which, together with ancient drawings and documents, is used for generating the first reconstructive step. Such rough approximation of a possible architectural structure can be annotated through archaeological considerations that has to be confronted with geometrical constraints, producing a reduction of the reconstructive hypotheses to a limited set, each one to be archaeologically evaluated. This refinement loop on the reconstructive choices is iterated until the result become convincing by both points of view, integrating in the best way all the available sources. The proposed method has been verified on the ruins of five temples in the My Son site, a wide archaeological area located in central Vietnam. The integration of 3D surveyed data and historical documentation has allowed to support a digital reconstruction of not existing architectures, developing their three-dimensional digital models step by step, from rough shapes to highly sophisticate virtual prototypes.

Importance of patient-specific intraoperative guides in complex maxillofacial reconstruction

BackgroundConventional maxillofacial reconstruction often leads to suboptimal results due to inaccurate planning or surgical difficulties in adjusting a free flap and osteosynthesis plates into a three-dimensional defect. ObjectivesTo justify the importance of patient-specific intraoperative guides in complex maxillofacial reconstruction. Clinical exampleA 40-year old patient underwent a left hemimaxillectomy for an adenoid cystic carcinoma of the palate. Six years later, massive recurrence required radical resection of the left orbit and reconstruction with cranial bone grafts and a free latissimus dorsi flap. Postoperative radiotherapy resulted in local osteoradionecrosis. Surgical revision and restoration of the maxillary defect with a prefabricated fibula flap was performed. The authors provide ample information on the application of computer-aided design and manufacturing (CAD-CAM) and rapid prototyping at each reconstructive step. DiscussionStereolithographic models enable simulation of the resective and reconstructive phases, prebending of reconstruction plates and fabrication of surgical guides. ConclusionsOptimal restitution of complex maxillofacial defects requires meticulous planning of the surgical and prosthetic phases and effective transfer of the plan to the operating room through patient specific guides. CAD-CAM technology and stereolithographic models represent an effective strategy to achieve this. Improved patient outcomes and intraoperative efficiency certainly offset the inherent increase in costs.

Posterior Muscolofascial Reconstruction Incorporated into Urethrovescical Anastomosis During Robot-Assisted Radical Prostatectomy

The rationale of posterior musculofascial plate reconstruction during radical prostatectomy is to shorten the time to reach urinary continence recovery and to reduce the risk of bleeding and anastomosis leakage. We describe our original technique incorporating the posterior muscolofascial reconstruction into urethrovesical anastomosis using robot-assisted radical prostatectomy (RARP). For this reconstructive step, we use a 30-cm V-Loc 90 3-0 barbed suture (V-20 tapered needle). Specifically, the free edge of the posterior layer of the Denonvilliers fascia is approximated to the posterior part of the sphincteric apparatus in a running fashion from left to right. The musculature of the urethral wall is incorporated in this first layer of the running suture. This suture is then continued back to the left in a second layer incorporating the anterior layer of the Denonvilliers fascia (or prostatovesical muscle), the bladder neck, and again the urethra, this time also with urethral mucosa. The urethrovesical anastomosis is completed using a second running barbed suture (15-cm V-Loc 90 3-0 barbed suture, V-20 tapered needle). No intraoperative complications were observed during this step of the procedure. Anastomotic leakages were observed only in 2% of cases. Only 12.5% showed urinary incontinence after catheter removal (1-2 pads). At mean follow-up of 9 months, the urinary continence recovery was 95%, and an anastomosis stricture necessitating an endoscopic incision developed in only three (1.5%) patients. Recent systematic reviews of the literature showed only a minimal advantage in favor of posterior musculofascial reconstruction in terms of urinary continence recovery within 1 month after radical prostatectomy. We support the use of this step of RARP because it is simple, reproducible, with a very limited increase in operative time, and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.

A standardized grading scale for reconstructive process surgery in head and neck cancer.

e16000 Background: Following carcinologic operative step, head and neck cancer surgery requires a reconstructive step involving local or regional, pedicled or free flaps. Although the reconstructive technique specifics depend mainly on the surgical team, the functional goal is so important that the best choice should be fully understood and discussed by the multidisciplinary team, including all involved medical staff. At the present time, the too numerous reconstructive procedures explain the great difficulty in including surgical reconstructive treatments in head and neck cancer prospective international studies, particularly in functional and quality of life evaluation. Methods: We have retrospectively established this scale in head and neck reconstructive surgery, based on 197 pedicled flaps and 225 free flaps performed from 2004 to 2008. Results: Therefore, we are proposing the Poissonville 2009 grading scale (Table), gathering the various head and neck reconstructive procedures according to the surgical difficulty and duration. It can be easily applied to any head and neck anatomical area. Conclusions: This scale is aiming at including the reconstructive step within the existing therapeutic guidelines, allowing the inclusion of the patient's medical condition and functional requirements in the therapeutic choice. Moreover, the cost effectiveness of the surgery could be evaluated by this scale according to the surgical procedure as others cancer staging classifications. Standardized grading scale of flaps for head and neck reconstructive surgery (Poissonville 2009) S type Without flap Direct suture, healing, skin graft M type Local pedicled flaps FAMM, myocutaneous buccinator, nasolabial L type Regional head and neck pedicled flaps Platysma, infrahyoid myocutaneous, temporoparietal fascia XL type Beyond head and neck area pedicled flaps Myocutaneous pectoralis major, myocutaneous latissimus dorsi XXL type Free flaps with microvascular surgery NB(no bone) Fasciocutaneous or myocutaneous flaps Radial forearm, anterolateral thigh, lateral arm, scapular, latissimus dorsi B(bone) Osteocutaneous flaps Fibular, scapular, iliac crest D Digestive flaps Digestive Jejunal, gastro-omental No significant financial relationships to disclose.

Laparoscopic radical cystectomy: an Italian survey

Radical cystectomy with urinary diversion is the current gold standard procedure for muscle-invasive bladder cancer. However, laparoscopic radical cystectomy (LRC) has evolved rapidly worldwide during the past decade, despite its complexity due to both the demolitive step with management of a highly aggressive cancer and the reconstructive step. The authors performed a survey to assess the Italian experience with LRC and urinary diversion in an effort to point out the volume of the procedure in their country, providing some surgical details. A total of 10 Italian urologic departments with experts in laparoscopic urologic surgery were contacted and asked to participate in a two-page survey concerning indications for cystectomy, laparoscopic technique, intra- and postoperative complications, and follow-up evaluation of the procedure when available. Five sites elected to participate, and a total of 83 LRCs were collected. All centers used five trocar ports. The mean operative time was 8 h and 40 min, and the estimated blood loss was 376 ml. In two cases, the procedure was converted to open surgery. Postoperative complications consisted of one urinary leakage, one fistula, and one atrium rupture. A retrieval sac was used in all cases. Urinary diversions consisted of 43 ileal conduits, 26 orthotopic diversions, and 14 other techniques. The mean follow-up period was 9 months (range, 1-36 months). No tumor seeding was recorded. The LRC procedure is feasible although technically demanding. The morbidity of this procedure is evident, but may be reduced with further experience. Bowel management and reconstruction remain the most challenging part of the procedure.