Safety Of Placement Research Articles

430 Trans-cerebellar Stereotactic-guided Cisternoperitoneal Shunt Placement for Idiopathic Intracranial Hypertension

INTRODUCTION: Idiopathic intracranial hypertension (IIH, pseudotumor cerebri) mainly affects young, obese females and can cause debilitating symptoms as well as optic nerve ischemia if not treated. Cerebrospinal fluid (CSF) diversion is often necessary to reduce intracranial pressure (ICP). Ventriculoperitoneal shunts (VPS) and lumboperitoneal shunts (LPS) are the main methods of CSF diversion but both are fraught with high rates of shunt failures in IIH patients. We propose the novel trans-cerebellar stereotactic-guided cisternoperitoneal shunt (TCSG-CPS) technique, which places the proximal shunt catheter in the posterior cisterna magnum, which is a non-collapsible CSF space. METHODS: Retrospective data regarding perioperative and postoperative data from all patients who underwent TCSG-CPS placement from 2015-2020 for IIH were collected. Intraoperatively, patients are positioned as for VPS but with the head turned further laterally to adequately expose the retrosigmoid space. Using neuronavigation, the transverse and sigmoid sinuses are located and an opening is made at the transverse-sigmoid junction. The proximal catheter is then inserted transcerebellarly into the posterior foramen magnum using electromagnetic neuronavigation to accurately track the catheter tip. RESULTS: Thirty-two patients underwent TCSG-CPS placement. 91% were female, with a mean BMI of 36.0 ± 7.5. Fourteen patients had undergone prior VPS or LPS placement with shunt failures. Shunt placement, including removal of prior shunts when applicable, took an average of 150 minutes. There were no intraoperative complications and patients were discharged uneventfully after mean 1.7 days. On follow-up visits at 6 months, 81% had relief of their presenting symptoms. Shunt survival without revision at 1 and 3 year were 86% and 67%, respectively. Overall infection rate was 0% in the study period. CONCLUSION: The TCSG-CPS offers an alternative solution to VPS and LPS for CSF diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared to historical data on VPS and LPS. Using the proper techniques and equipment promotes safe and facile placement of the proximal catheter.

Clinical accuracy and initial experience with augmented reality-assisted pedicle screw placement: the first 205 screws.

Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system. A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors' institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion. Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall. AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.

Double Sublaminal Band Passage Technique for Spinal Deformity Correction.

Sublaminar band fixation is a reliable way to anchor spinal rods to the vertebral column. This technique is especially useful when the anatomy precludes safe pedicle screw placement. Sublaminar bands allow for deformity correction and stabilization of the spine. One of the disadvantages of using the sublaminar band technique is the risk for neurologic injury during the passage of the band between the dura and lamina. In this article, we describe a new technique for passing sublaminar bands, i.e., the double sublaminar band passage technique. This technique decreases the number of passes against the dura, thereby decreasing the opportunity for neural injury. In addition, we present an illustrative case of an 11-year-old female with neuromuscular scoliosis who underwent a posterior spinal instrumented fusion with a hybrid screw and sublaminar band construct.

Complications in Elbow Arthroscopy: Management and Prevention.

With advances in the understanding of elbow anatomy, pathologies of the elbow, arthroscopic instrumentation, and surgical techniques over recent decades, elbow arthroscopy has become a valuable treatment modality for a variety of conditions. Elbow arthroscopy has gained utility for treating problems such as septic arthritis, osteoarthritis, synovitis, osteophyte and loose body excision, contracture release, osteochondral defects, select fractures, instability, and lateral epicondylitis. Accordingly, precise knowledge of the neurovascular anatomy, safe arthroscopic portal placement, indications, and potential complications are required to maximize patient outcomes and assist in educating patients. This comprehensive review provides the reader an understanding of the potential complications associated with arthroscopic procedures of the elbow and to describe strategies for prevention and management.

Can C1 lateral mass and C3 pedicle screw fixation be used as an option for atlantoaxial reduction and stabilization in Klippel-Feil patients? A study of its morphological feasibility, technical nuances, and clinical efficiency

In Klippel-Feil patients with atlantoaxial dislocation, narrow C2 pedicles are often encountered preventing pedicle screw placement. Alternative techniques, including translaminar screws, pars screws, and inferior process screws could not achieve 3-column rigid fixation, and have shown inferior biomechanical stability. The present study aimed to evaluate the feasibility, safety, and efficacy of C3 pedicle screws (C3PSs) as an option for atlantoaxial stabilization in Klippel-Feil patients, and to introduce a freehand technique, the "medial sliding technique," for safe and accurate C3PS insertion. Thirty-seven Klippel-Feil patients with congenital C2-3 fusion who have received atlantoaxial fixation were reviewed. Preoperative CT and CT angiography were acquired to evaluate the feasibility of C3PS placement. C1 lateral mass and C3PS constructs were used for atlantoaxial stabilization. The "medial sliding technique" was introduced to facilitate C3PS insertion. Clinical outcomes and complications were evaluated, and screw accuracy was graded on postoperative CT scans. Morphological measurements showed that more than 80% C3 pedicles could accommodate a 3.5-mm screw. Fifty-eight C3PSs were placed in 33/37 patients using the medial sliding technique. Overall, 96.7% screws were considered safe and there was no related neurovascular complications; 27/33 patients exhibited neurological improvement and 30/33 patients had a solid bone fusion at an average 19.3-month follow-up. Therefore, the C3PS was a feasible option for atlantoaxial fixation in Klippel-Feil patients. The clinically efficiency of C3PS was satisfied with high fusion rates and low complications. The medial sliding technique we used could facilitate safe and accurate placement of C3PSs in Klippel-Feil patients with fused C2-3 vertebra.

Jig-assisted modified Harrington reconstruction for metastatic bone destruction of the acetabulum.

We developed a technique using an indigenously designed jig to assist pin placement in producing a stable and long-lasting construct to augment the acetabulum combined with a cemented hip replacement in cases of metastatic destruction of the acetabulum. We describe our novel modified Harrington technique and retrospectively assess our cohort's clinical outcomes and complications. Between 2006 and 2019, 27 patients with a median age of 69 (49-81) years and a median ASA grade of III (II-IV) were managed using our modified 'Harrington' technique. We assessed outcomes on the following criteria: mechanical complications, post-surgery mobility, and functional outcome using Musculoskeletal Tumour Society Score (MSTS). At the last follow-up, ten patients were alive with disease [median follow-up of 26months (12-74)], and 17 patients died of their oncological disease [median follow-up of 15months (9-22)]. There were no perioperative deaths or intra-operative complications in our series. In total, ten complications were noted in nine patients (33%). Mobility-wise, 13 patients (48%) mobilised unaided, ten patients (37%) required a stick or crutch, two patients (7%) required a frame and two patients (7%) were wheel chair-dependent. The median MSTS score of all patients during their latest follow-up was 18 (8-26). Our jig-aided modified Harrington reconstruction technique assists in safe placement of antegrade pins in acetabulum during surgery and offers a long-lasting solution to these high-risk patients. The use of large diameter pins, appropriate patient selection, and cage used during construction in the acetabulum demonstrated relief of pain, improved mobility, and favorable functional outcomes with minimal complication rates.

HYBRID AORTIC ARCH SURGERY TO CREATE A LANDING ZONE IN THE ASCENDING AORTA.

Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.

DEVELOPMENT OF METHOD AND SOFTWARE FOR COMPRESSION AND ENCRYPTION OF INFORMATION

Researches of the subject area of lossless information compression and with data loss are carried out and data compression algorithms with minimal redundancy are considered: Shannon-Fano coding, Huffman coding and compression using a dictionary: Lempel-Ziv coding. In the course of the work, the theoretical foundations of data compression were used, studies of various methods of data compression were carried out, the best methods of archiving with encryption and storage of various kinds of data were identified. The method of archiving data in the work is used for the purpose of safe and rational placement of information on external media and its protection from deliberate or accidental destruction or loss. In the Embarcadero RAD Studio XE8 integrated development environment, a software package for an archiver with code protection of information has been developed. The archiverʼs mechanism of operation is based on the creation and processing of streaming data. The core of the archiver is the function of compressing and decompressing files using the Lempel-Ziv method. As a method and means of protecting information in the archive, poly-alphabetic substitution (Viziner cipher) was used. The results of the work, in particular, the developed software can be practically used for archival storage of protected information; the mechanism of data archiving and encryption can be used in information transmission systems in order to reduce network traffic and ensure data security. The resulting encryption and archiving software was used in the module of the software package «Diplomas SNU v.2.6.1», which was developed at the Volodymyr Dal East Ukrainian National University. This complex is designed to create a unified register of diplomas at the university, automate the creation of files-diplomas of higher education in the multifunctional graphics editor Adobe Photoshop. The controller exports all data for analysis and formation of diplomas from the parameters of the corresponding XML files downloaded from the unified state education database in compressed zip archives. The developed module performs the process of unzipping and receiving XML-files with parameters for the further work of the complex «Diplomas SNU v.2.6.1».

Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery?

The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of "ideal" pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the "optimal screw," maximizing construct stability and, thus, the ability to obtain a successful fusion.

Tracheobronchoplasty for tracheobronchomalacia.

Tracheobronchoplasty (TBP) consists of splinting of the posterior membranous wall of the central airways with the goal of restoring a normal configuration and preventing excessive collapse in patients with tracheobronchomalacia (TBM). Despite some variation in technique, it consists of sewing a mesh on the posterior membranous wall of the trachea and both main stem bronchi. Traditionally performed through a right posterolateral thoracotomy, it should be reserved for cases of severe TBM. Surgical exposure necessitates dissection of the trachea from the thoracic inlet to the carina, as well the right main stem bronchus, bronchus intermedius and left main stem bronchus. Airway management in the operating room requires manipulation of the endotracheal tube (ETT) to allow safe placement of the sutures without puncturing the balloon. Other key technical considerations include downsizing of the airway with the mesh, and appropriate spacing of the sutures to ensure a plicating effect of the posterior membranous wall. More recently the robotic platform was used to perform TBP surgery. Its fine precise wristed motion and excellent visualization offer potential advantages over a thoracotomy and early outcomes of robotic-assisted TBP are encouraging. Longitudinal follow-up is still necessary to ensure the durability of repair in a patient population with significant underlying respiratory co-morbidities.

Hip Spica Stroller: A Technical Note.

Care of the child after hip-spica application is the most challenging issue faced by parents. Reduced mobility and recumbency can cause respiratory problems, skin irritation and discomfort for the child. Parents need to lift the child in a spica to make him upright and to mobilize. To improve the comfort of the family in post spica care, we have designed a 'Hip Spica Stroller' which is low profile, comfortable, easy to construct and relatively inexpensive. This manuscript discusses our early experience with this hip-spica stroller use. A sturdy, relatively lightweight and portable stroller was designed in collaboration with local mechanical engineering team. The stroller allowed safe upright placement of the child with spica and their easy mobility. From the second post-operative day, children were mobilised in the stroller. We looked for development of any complications related to the stroller such as spica breakage, skin irritation or excoriation development. Parents were also inquired about their feedback and satisfaction with the device upon spica removal. We used the spica stroller in nine patients after Developmental Dysplasia Hip (DDH) treatment and in eight patients post shaft femur fracture treatment. None of the patients experienced any stroller-related complications. All the patients maintained the joint reduction and the fractured bone fragment alignment. High satisfaction rates were reported by parents. Hip Spica Stroller is an innovative and easy-to-make device which would enhance the post spica care. It can aid alleviating the fear of parents for their child's hip-spica treatment. The online version contains supplementary material available at 10.1007/s43465-021-00568-2.

Abstract 11571: Defining the Distance Between the His Bundle and Septal Perforator Arteries

Introduction: Left bundle branch pacing (LBBP) is an emerging pacing modality in which the LBBP lead is screwed through the interventricular septum towards the left bundle branch in the left septal subendocardium. Damage to a septal perforating branch of the left anterior descending coronary artery is a potential complication. Objective: To define the distance between the His bundle and the first septal perforator artery to guide safe LBBP lead placement. Methods: Clinically indicated coronary CT angiograms (CCTA) at our institution were reviewed. The intersection of the tricuspid annulus and the base of the non-coronary cusp of the aortic valve represented the location of the His bundle. The intersection of a line joining the His bundle location with the RV apex with the first septal perforator was determined. The distance between the His Bundle and this intersection was measured and recorded. Values were analyzed using standard statistical methods. T-tests were used for continuous variables. Results: A total of 50 consecutive CCTAs were included in this study, 30 men and 20 women, average age 55.4 ± 14.1 years. Medical history included HTN (64%), and diabetes (50%) and CAD (10%). LVH was present in 9 patients (18%) but was mild in all cases. Heart failure was present in 9 patients (18%), 4 of whom had systolic dysfunction with an average EF for the study being 57.0%. The mean left ventricular internal diameter at end diastole (LVIDd) and interventricular septum thickness (IVS) were 46.7 mm and 10.2 mm, respectively. The mean distance from the His Bundle to the first septal perforator was 27.2 ± 7.7 mm, median 26.9 mm, range 13.0 to 44.7 mm. There was no significant difference by gender for mean distance (28.1 mm men vs 25.6 mm women, p=0.26). There was no significant association between LVIDd or IVS and the His Bundle-Septal Perforator distance (r 2 =0.02 and r 2 =0.002, respectively). Conclusions: Using CCTA, we defined the distance between the His bundle and the first septal perforator. Operators implanting LBBP leads can use these measurements to guide safe lead placement.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

BackgroundRisk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy.MethodsFirst, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed.ResultsWe utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases.ConclusionOur technique of NGT placement is simple, safe, and feasible.

1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection

Abstract Introduction Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy. Method In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid. Results A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics. Conclusions Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.

Multimodal Spinal Cord Mapping during Spinal Cord Stimulator Placement: Technical Note

ABSTRACT Spinal cord stimulation is used to treat patients with severe neuropathic pain and other forms of debilitating back pain. Spinal cord stimulators (SCS) can either be placed under sedation or general anesthesia (GA). This study evaluated the utility of neurogenic evoked potentials in enabling multimodal spinal cord mapping (MSCM) for the placement of SCSs under GA. The goal of our MSCM paradigm, which integrated recordings from multiple antidromic and orthodromic generators, was to enable the use of precise neuromonitoring techniques, typically used for localizing the midline of the dorsal spinal cord in intramedullary tumor cases, for the safe placement of SCSs. Two distinct modalities were incorporated - orthodromic responses from the somatosensory cortex (Cp3-Cp4 cancellation) and antidromic stimulation via the SCS which resulted in compound nerve action potentials of the extremities. In addition, two incidental findings were made. First, our results suggest that previous investigations may have incorrectly identified compound muscle action potentials as compound nerve action potentials. Additionally, anti D-wave responses, that are theorized to be the equivalent of a D-wave, were observed. This manuscript describes the first use of MSCM, which will ultimately provide neurophysiologists more information during SCS implantation, enabling them to confirm midline placement more confidently. MSCM also allows the application of techniques typically used in spinal cord tumors, allowing the neurophysiologist to maintain proficiency with these techniques on more common procedures. The parallel collection of several sources of data will allow for future studies that better define which mapping methods are the most accurate.

Quantitative Analysis of Temporal Bone Density and Thickness for Robotic Ear Surgery.

Background and Objective: Quantitative assessment of bone density and thickness in computed-tomography images offers great potential for preoperative planning procedures in robotic ear surgery.Methods: We retrospectively analyzed computed-tomography scans of subjects undergoing cochlear implantation (N = 39). In addition, scans of Thiel-fixated ex-vivo specimens were analyzed (N = 15). To estimate bone mineral density, quantitative computed-tomography data were obtained using a calibration phantom. The temporal bone thickness and cortical bone density were systematically assessed at retroauricular positions using an automated algorithm referenced by an anatomy-based coordinate system. Two indices are proposed to include information of bone density and thickness for the preoperative assessment of safe screw positions (Screw Implantation Safety Index, SISI) and mass distribution (Column Density Index, CODI). Linear mixed-effects models were used to assess the effects of age, gender, ear side and position on bone thickness, cortical bone density and the distribution of the indices.Results: Age, gender, and ear side only had negligible effects on temporal bone thickness and cortical bone density. The average radiodensity of cortical bone was 1,511 Hounsfield units, corresponding to a bone mineral density of 1,145 mg HA/cm3. Temporal bone thickness and cortical bone density depend on the distance from Henle's spine in posterior direction. Moreover, safe screw placement locations can be identified by computation of the SISI distribution. A local maximum in mass distribution was observed posteriorly to the supramastoid crest.Conclusions: We provide quantitative information about temporal bone density and thickness for applications in robotic and computer-assisted ear surgery. The proposed preoperative indices (SISI and CODI) can be applied to patient-specific cases to identify optimal regions with respect to bone density and thickness for safe screw placement and effective implant positioning.

Prepontine placement of an intrathecal baclofen pump catheter for treatment of dystonia

Background: Cerebral palsy with medically refractory spasticity and dystonia is a condition that often benefits from intrathecal baclofen pump therapy to treat these symptoms. In this case report, an intracranial baclofen catheter was placed in the prepontine space to improve withdrawal symptoms in a patient unable to undergo new lumbar catheter placement due to infection.Case Description: A 22-year-old female with past medical history of cerebral palsy presented with baclofen pump failure and was unable to undergo placement of a new lumbar baclofen catheter due to an infection in her lower back precluding safe and efficacious catheter placement. It was decided the patient would benefit from intrathecal baclofen administered in the prepontine space as a means to avoid a lumbar catheter and thus bypass this prior infection site. An endoscopic third ventriculostomy (ETV) was performed with the endoscope and the distal end of the baclofen pump catheter was fed through this ETV into the prepontine space. Placement in the prepontine space was confirmed by a follow-up head computed tomography. There was a significant improvement in autonomic symptoms and spasticity. By postoperative day 5, the patient was surgically and medically cleared for discharge.Conclusion: In cases of severe baclofen withdrawal due to dysfunctional pumps, immediate reversal is preferred but may not be feasible due to factors such as infection. This case report has demonstrated that prepontine catheter placement can be effective for the administration of baclofen to reverse withdrawal symptoms in these types of patients.

3D Guided Dental Implant Placement: Impact on Surgical Accuracy and Collateral Damage to the Inferior Alveolar Nerve.

An increase in the number of implants placed has led to a corresponding increase in the number of complications reported. The complications can vary from restorative complications due to poor placement to damage to collateral structures such as nerves and adjacent teeth. A large majority of these complications can be avoided if the implant has been placed accurately in the optimal position. Therefore, the aim of this in vitro pilot study was to investigate the effect of freehand (FH) and fully guided (FG) surgery on the accuracy of implants placed in close proximity to vital structures such as the inferior alveolar nerve (IAN). Cone-beam computed tomography (CBCT) and intraoral scans of six patients who have had previous dental implants in the posterior mandible were used in this study. The ideal implant position was planned. FG surgical guides were manufactured for each case. In this study, the three-dimensional 3D printed resin models of each of the cases were produced and the implants placed using FG and FH methods on the respective models. The outcome variables of the study, angular deviations were calculated and the distance to the IAN was measured. The mean deviations for the planned position observed were 1.10 mm coronally, 1.88 mm apically with up to 6.3 degrees’ angular deviation for FH surgery. For FG surgical technique the mean deviation was found to be at 0.35 mm coronally, 0.43 mm apically with 0.78 degrees angularly respectively. The maximum deviation from the planned position for the apex of the implant to the IAN was 2.55 mm using FH and 0.63 mm FG. This bench study, within its limitations, demonstrated surgically acceptable accuracy for both FH and FG techniques that would allow safe placement of implants to vital structures such as the IAN when a safety zone of 3 mm is allowed. Nevertheless, a better margin of error was observed for FG surgery with respect to the angular deviation and controlling the distance of the implant to the IAN using R2 Gate® system.

V11-09 ROBOTIC MODIFIED BALLOON-LESS RETROPERITONEAL APPROACH FOR POSTERIOR RENAL MASSES

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-09 ROBOTIC MODIFIED BALLOON-LESS RETROPERITONEAL APPROACH FOR POSTERIOR RENAL MASSES Thomas Lowrey, Jacob Allen, Daniel Parker, Andrew McIntosh, and Sanjay Patel Thomas LowreyThomas Lowrey More articles by this author , Jacob AllenJacob Allen More articles by this author , Daniel ParkerDaniel Parker More articles by this author , Andrew McIntoshAndrew McIntosh More articles by this author , and Sanjay PatelSanjay Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video demonstration will describe an efficient modified robotic retroperitoneal approach for posterior renal masses, avoiding the need for balloon dilation and extensive defatting in the traditional approach. METHODS: The patient is placed in the 90 degree flank position. A 5 mm laparoscope is placed 4 cm superior to the umbilicus at the midclavicular line, which will aid in visualizing placement of the working robotic ports. The reflection of the peritoneum at the white line of Toldt is identified in order to mark the robotic camera port site 2 fingerbreadths above the iliac crest. Two medial 8-mm robotic ports are placed 2 fingerbreadths above the iliac crest and 8 cm apart using the robotic camera port as reference. Next, with laparoscopic scissors and Kittner Dissector, the lateral side wall attachments to the colon are taken down creating space to safely place the camera port and lateral most trocar. Using a 30 degree upward scope, the peritoneum along white line of Toldt and lateral kidney attachments are incised up to the splenic flexure or hepatic flexure. Complete incision of the peritoneum allows the kidney to naturally flop medially thereby doubling the working space as compared to the traditional approach. Once the white line of Toldt is mobilized, the 4th arm lifts the kidney to place the hilum on traction. After Gerota’s fascia is incised and the hilum identified, standard partial nephrectomy is performed. RESULTS: A total of 15 patients underwent this new technique without any Clavien 1-4 complications. The technique allows for efficient port placement without the need for: blind finger entry, balloon dilation, tedious dissection and sweeping of the peritoneum required for port placement, and extensive defatting of the pararenal fat to create the retroperitoneal space. The port location in this technique is the same as the traditional retroperitoneal approach, thus affording the same view with increased working space and improved visualization of landmarks. Insufflation is also more consistent given less air leaks from inadvertent peritoneal tears and from the balloon dilating port site. CONCLUSIONS: This modified retroperitoneal approach allows for quick, efficient, and safe port placement resulting in larger working space and excellent visualization of anatomical landmarks without the need for complicated retroperitoneal balloon dilation, sweeping of peritoneum for port placement, and defatting of the pararenal fat. Since the development of this technique, we have abandoned the traditional robotic retroperitoneal approach with balloon dilation at our institution. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e860-e860 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Lowrey More articles by this author Jacob Allen More articles by this author Daniel Parker More articles by this author Andrew McIntosh More articles by this author Sanjay Patel More articles by this author Expand All Advertisement Loading ...

MP57-06 THE URETHRAL MICROBIOME DURING INFLATABLE PENILE PROSTHESIS PLACEMENT

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy (MP57)1 Sep 2021MP57-06 THE URETHRAL MICROBIOME DURING INFLATABLE PENILE PROSTHESIS PLACEMENT John Williams, Hayden Hill, Eric Wendel, and Eric Laborde John Williams John Williams More articles by this author , Hayden HillHayden Hill More articles by this author , Eric WendelEric Wendel More articles by this author , and Eric LabordeEric Laborde More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002087.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Foley catheter placement prior to inflatable penile prosthesis (IPP) implantation permits drainage of the bladder to ensure safe retropubic reservoir placement and allows for palpation of the urethra to prevent inadvertent injury. The urethra is often colonized with commensal organisms mostly concentrated at the meatus and fossa navicularis to which the Foley catheter is exposed during placement. Following placement, the catheter remains on the sterile field during surgery. We sought to investigate if the microbiome of the urethra could contaminate the Foley catheter during IPP placement. METHODS: Data was retrospectively reviewed on all patients who underwent three-piece IPP placement at a single institution from 2/2020 to 2/2021. Patient demographics, clinical characteristics, and comorbidities were recorded. Culture swabs from the fossa navicularis and exposed Foley catheter were collected intra-operatively after Foley catheter placement. Growth of aerobic, anaerobic, and fungal organisms was assessed. Univariate analyses with chi-square tests were performed to compare baseline demographic and clinical data with isolation of organisms from culture swabs. RESULTS: A total of 40 patients were included in this study. All surgeries were performed via penoscrotal approach by a single surgeon. 20% (n=8) were revision procedures, all of which were due to mechanical device malfunction. The mean age of our cohort was 65 years (range: 42-78 years) and 35% (n=14) had a BMI of 30 kg/m2 or greater. Three patients (8%) were current smokers and 48% (n=19) were diabetic. Two patients (5%) had isolation of aerobic organisms and five patients (13%) had isolation of anaerobic organisms. No patients had isolation of fungal organisms. There was no statistically significant relationship between obese BMI, diabetes diagnosis, or current smoking and the isolation of organisms. No patients have currently shown evidence of device infection. CONCLUSIONS: A number of patients had isolation of aerobic and anaerobic organisms from their intra-operatively collected cultures. This is the first study to examine the urethral microbiome and its potential effect on Foley catheter contamination at the time of IPP placement. Further study is needed to determine if this could be a significant source of device infection. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e980-e980 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Williams More articles by this author Hayden Hill More articles by this author Eric Wendel More articles by this author Eric Laborde More articles by this author Expand All Advertisement Loading ...