Sequential Dilation Research Articles

Necessity sequential intermediate kissing balloon dilation for crush stenting: Further insights from metal/polymer vessel scaffolds bench testing.

Sequential intermediate kissing balloon dilation (sIKBD) is crucial for crush stenting, but it require appropriate procedure remains unclear for crush stenting. This study aims to investigate whether sIKBD is necessary and how it can be properly performed during crush stenting. Mini-crush stenting (mini-CS) and sIKBD for mini-crush stenting (sIKBD-mini-CS) using metal drug-eluting stents/polymer bioresorbable vessel scaffolds (mDES/pBVS) were emulated in bifurcation models considering the branch diameter difference, and sIKBD was added to mini-CS for pretreating side-branch (SB) stent before main-branch (MB) stenting (second figure), respectively. Micro-computed tomography was used to assess the morphological parameters of bifurcated stents including length of overlapping stent segment, residual ostial stenosis of the SB, and neocarina length using quantitative methods. Further, optical coherence tomography was to analyze the incidence of stent malapposition. Quantitative analysis demonstrated that in mDES/pBVS phantom, the neocarina length (mDES: 0.45 ± 0.10 mm vs 0.30 ± 0.09 mm, P = .005; pBVS: 0.47 ± 0.11 mm vs 0.29 ± 0.09 mm, P = .001), residual ostial stenosis at the SB (mDES: 19.37 ± 8.21% vs 12.47 ± 2.05%, P = .001; pBVS: 21.89 ± 8.54% vs 9.98 ± 3.35%, P = .035), and stent malapposition in the overlapping segment (mDES: 10.29 ± 3.31% vs 3.83 ± 0.97%, P = .001; pBVS: 12.05 ± 3.87% vs 6.40 ± 1.59%, P = .003) were lower in the sIKBD-mini-CS group than those in the mini-CS group (P < .05 for all). The results of factorial analysis showed that mDES platform tended to have better morphological indicators than the pBVS platform. Adding the sIKBD to mini-CS showed better morphologic characteristics of mDES/pBVS phantoms when compared with mini-CS. Therefore, it should be considered as a critical and proper technique for crush stenting.

Activation mechanisms of dimeric mechanosensitive OSCA/TMEM63 channels

OSCA/TMEM63 channels, which have transporter-like architectures, are bona fide mechanosensitive (MS) ion channels that sense high-threshold mechanical forces in eukaryotic cells. The activation mechanism of these transporter-like channels is not fully understood. Here we report cryo-EM structures of a dimeric OSCA/TMEM63 pore mutant OSCA1.1-F516A with a sequentially extracellular dilated pore in a detergent environment. These structures suggest that the extracellular pore sequential dilation resembles a flower blooming and couples to a sequential contraction of each monomer subunit towards the dimer interface and subsequent extrusion of the dimer interface lipids. Interestingly, while OSCA1.1-F516A remains non-conducting in the native lipid environment, it can be directly activated by lyso-phosphatidylcholine (Lyso-PC) with reduced single-channel conductance. Structural analysis of OSCA1.1-F516A in lyso-PC-free and lyso-PC-containing lipid nanodiscs indicates that lyso-PC induces intracellular pore dilation by attracting the M6b to upward movement away from the intracellular side thus extending the intracellular pore. Further functional studies indicate that full activation of MS OSCA/TMEM63 dimeric channels by high-threshold mechanical force also involves the opening of both intercellular and extracellular pores. Our results provide the fundamental activation paradigm of the unique transporter-like MS OSCA/TMEM63 channels, which is likely applicable to functional branches of the TMEM63/TMEM16/TMC superfamilies.

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes

IntroductionCulotte stenting is an effective strategy for left main coronary bifurcation lesions. Increased side branch ostial restenosis is the main drawback of Culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al. has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. AimWe report immediate and short-term results of Double Kissing (DK) mini-Culotte stenting with a one-year angiographic follow-up. MethodsForty-five patients of distal left main (LM) disease underwent DK mini-Culotte stenting at our center between March 2020 and December 2022 under Optical Coherence Tomography (OCT) guidance. ResultsOut of 45 patients [male:35(77.77%); mean age:63.67±4.94years], chronic coronary syndrome was present in 26(57.8%) and unstable angina in rest. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1) with a median Syntax score of 28 (IQR=23-29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under OCT guidance, adequate minimal stent area (MSA) of 13.28 ± 0.77mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45mm2 was achieved in LM, left anterior descending (LAD) and left circumflex (LCx) respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events (MACE) was 2.2%. Further, one (2.2%) patient developed restenosis of the side branch which was managed conservatively. ConclusionDK mini-Culotte stenting in the distal left main bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

A Novel Marking Technique for Accurate Minimal Invasive Approaches in Spine Tumor Surgeries With Activated Carbon Marking.

To describe a novel, practical, reproducible, and effective preoperative marking technique for accurate localization of the spinal level in a series of patients with tumor lesions. We retrospectively analyzed patients undergoing minimally invasive (MIS) surgery for spine tumors from 2016 to 2021, in which this marking technique was used. Twenty-one patients, with tumor lesions involving difficult radioscopic visualization (cervicothoracic junction or upper dorsal spine, C6-T8), were included. Tumor lesion level was previously determined with enhanced MRI in all cases. Twenty-four to forty-eight hours before surgery, computed tomography image-guided carbon marking was performed by administration of aqueous suspension of carbon with a 21-gauge needle placed resembling the MIS approach planned trajectory. During surgery, activated carbon marking was followed until reaching the final target on the bone. Next, sequential dilators and an MIS retractor were placed. Then, bone resection and tumor exeresis were performed according to the case. Average age was 60.6 years (26-76 years). Fifteen (71%) patients were women. In most cases (76%), tumor pathology involved intradural lesions (meningiomas and schwannomas). In all cases, the marking described allowed to accurately guide the MIS approach to tumor site. Neither intraoperative fluoroscopy nor approach enlargement was required in any procedure. Postoperative complications were reported in only 4 patients, none related with the marking. Computed tomography image-guided activated carbon marking allows to accurately lead MIS approaches in a practical, reproducible, and effective way in cases of tumors localized in regions of the spine of difficult radioscopic visualization.

The Utility of Magnetic Resonance Enterography and Double Balloon Enteroscopy-Assisted Endoscopic Balloon Dilatation for Small Bowel Strictures in Crohn’s Disease: A Retrospective Observational Study

Introduction: Crohn’s disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures. Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up. Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2–3 months. Surgery was not needed during the follow-up period. Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients.

The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation

BackgroundTunnelled cuffed haemodialysis catheters are at increased risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods of time. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. Whilst there are several strategies published for the removal of these incarcerated lines, there is no consensus on the best approach. Here we present a challenging case of a stuck haemodialysis catheter in the acute post transplantation period.Case PresentationA 66-year-old female on haemodialysis presented for kidney transplantation with a tunnelled-cuffed haemodialysis catheter in situ for five years. Following transplantation, removal of the line was unsuccessful despite dissection of the cuff, with traction causing a choking sensation with tracheal movement. Eventually, the line was removed without complications utilising sequential balloon dilatation by interventional radiology and the patient was discharged without complications.ConclusionsThis case serves as a timely reminder of the risks of long-term tunnelled haemodialysis catheters and as a caution towards proceeding with kidney transplantation in those with long-term haemodialysis catheters in situ. Greater nephrologist awareness of interventional radiology techniques for this challenging situation will help to avoid more invasive strategies. The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient.

Up and over staged endoconduit technique for endovascular aortic aneurysm repair

Adverse iliofemoral anatomy can preclude complex endovascular aortic aneurysm repair. This study aims to describe the “up-and-over” staged endoconduit technique to improve access and avoid vascular injury before complex endovascular aneurysm repair. A staged procedure for complex endovascular aortic aneurysm repair is performed using an endoconduit (W.L. Gore & Associates). After obtaining contralateral femoral access, the extension of iliofemoral disease is assessed using angiography. The endoconduit is advanced “up and over” the aortic bifurcation and delivered percutaneously into the common femoral artery to treat a diseased access site and maintain intact the ipsilateral femoral access for future stent graft deployment. Internal iliac artery patency is maintained when feasible. During complex aneurysm repair, the endoconduit is accessed directly under ultrasound guidance using sequential dilation to avoid vascular injury. PerClose sutures (Abbott Vascular) are used to close the endoconduit femoral access site. This study found that staged “up and over” endoconduit creation is a useful technique before complex endovascular aneurysm repair in patients with adverse iliofemoral anatomy. Avoiding accessing the main femoral access site during the first stage prevents vascular or access site injuries and allows for both iliac and femoral disease to be addressed.

Long-term outcomes of staged iliofemoral endoconduits prior to complex endovascular aortic aneurysm repair

ObjectiveAdverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (ECs) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral ECs prior to complex EVAR. MethodsBetween 2012 and 2023, 59 patients (44% male; median age, 75 ± 6 years) underwent ECs before complex EVAR using self-expanding covered stents (Viabahn). For common femoral artery (CFA) disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency. ResultsUnilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac, external iliac, and CFA were 7 mm (interquartile range [IQR], 6-8 mm), 6 mm (IQR, 5-7 mm), and 6 mm (IQR, 6-7 mm), respectively. Internal iliac artery was inadvertently excluded in 10 patients (17%). Six patients (10%) had an intraoperative vascular injury during the EC procedure, and six patients (10%) had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. In 23 patients (39%), 22 Fr OD devices were used; 20 Fr were used in 22 patients (37%), and 18 Fr in 14 patients (24%). Technical success for accessing EC was 89%. There was no difference in major adverse events at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82%, respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six secondary interventions (10%) were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up. ConclusionsECs improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the EC directly under ultrasound guidance and using sequential dilation to avoid EC disruption.

Sequential Depth Stimulation Within the Psoas Offers No Benefit for Localization of the Lumbar Plexus During Lateral Lumbar Fusion Surgery.

Prospective cohort study. In this study we aim to assess the difference in triggered EMG readings throughout different depths in the psoas muscle during the lateral approach to the lumbar spine and their effect on surgeon decision making. Three surgeons, practicing at different institutions, assessed triggered EMG readings during the trans psoas approach at the level of the disc and 5,10 and 15millimeters into the psoas muscle with sequential dilators. Measurement of distance into the psoas muscle was done with a specially designed instrument. Results of anterior and posterior directed stimulation as well as the delta value between these were recorded and underwent statistical analysis. Patients who had partial readings were excluded from the study. A total of 40 levels in 35 patients were included in the study. There was no significant difference found between means of anterior or posterior threshold readings along the different distance groups. A significant difference was found (P = .024) in the mean difference between the distance groups with a decrease in the difference between anterior and posterior threshold values found as the distance from the disc space increased. None of the surgeons reported a decision to abort the fusion of a spinal level. In the trans-psoas approach to the lumbar spine, the assessment of the location of the femoral nerve using directional neuromonitoring when advancing in the psoas muscle shows no clear benefit as opposed to stimulating solely when adjacent to the disc space.

Transseptal Puncture and Cryoballoon Ablation of Atrial Fibrillation in Patients with Atrial Septal Occluder or Atrial Septal Defect Surgical Repair: A Single Center Experience.

Atrial fibrillation (AF) is a common arrhythmia in patients with atrial septal defect (ASD). Cryoballoon ablation (CA) is a safe and efficient method for pulmonary vein (PV) isolation in the treatment of AF. Achieving left atrial access may be difficult in patients with atrial septal occluders (ASO) or surgical repair of ASD. The aim of this study was to present our experience with the efficacy and safety of transseptal puncture and AF ablation in CA in this subset of patients. We retrieved our data about patients with ASO or surgical repair of ASD undergoing cryoballoon AF ablation procedures at our center between August 2019 and January 2022. Nine patients (age 43.88 ± 9.73 years) with AF (5 paroxysmal and 4 persistent) and ASO or surgical repair of ASD were enrolled. All three patients had a 28 mm Amplatzer ASO device which occupied the whole septum, and direct puncture through the ASO was performed. Sequential balloon dilatation was performed in 2 patients with surgical ASD repair and all 3 patients with ASO. Four of 6 patients (66.7%) in the surgical repair group required transesophageal echocardiography during transseptal puncture. The endpoint of the procedure, isolation of all PVs, was achieved in all 9 patients. None of the patients had evidence of an interatrial shunt or pericardial effusion at the end of the procedure. Total procedural time (123 ± 28 minutes vs. 63 ± 21 minutes, P = .024) and total fluoroscopy time (41 ± 5 minutes vs. 23 ± 8 minutes, P = .024) were significantly higher in the percutaneous closure group. In patients with ASO or surgical repair of ASD, CA of AF might be feasible, safe, and effective. The balloon dilatation of the interatrial septum (IAS) might assist transseptal access through the ASO or a surgically repaired thickened IAS.

What is the safe and effective dilator number during access in PCNL? Three-shot dilation versus classical sequential Amplatz dilation

BackgroundAlthough PCNL has been used for a long time to treat nephrolithiasis, there is still contradictory information concerning the use of the dilation method. In this study, we aimed to compare conventional sequential Amplatz dilatation (SAD) using ten dilators and a method using three dilators (12, 20, and 30 Fr), which we named “three-shot dilatation” (3SD), in terms of fluoroscopy time (FT), operation time, bleeding and stone-free rates.MethodsThe study included patients who underwent PCNL with the SAD and 3SD methods. A different surgeon with extensive endourology experience applied each technique. One of the surgeons operated on the patients using the SAD method with ten dilators, and the other surgeon performed the operations using the 3SD method involving three Amplatz dilators (12, 20, and 30 Fr).ResultsA total of 283 patients, 138 in the 3SD group and 145 in the SAD group, were included in the study. The mean age of the patients was 47.32 ± 13.71 years. There was no statistically significant difference between the two groups regarding preoperative characteristics (p > 0.05). The FTs of access 2, total access, and total operation were significantly shorter in the 3SD group (p = 0.0001). The decrease in hemoglobin was statistically significant in the 3SD group compared to the SAD group (p = 0.022), while the blood transfusion requirements of the groups were similar (p = 0.176). There was no statistically significant difference between the two groups regarding stone-free rates (p = 0.973). In four patients in the SAD group, re-access was necessary due to the loss of passage due to the guide wire slipping out of its place.ConclusionIntraoperative FT can be shortened using the described 3SD method without compromising surgical safety. However, this method can be used as an intermediate step in the transition to one-shot dilation by surgeons experienced in performing SAD.

Separation of overlapping image objects using morphological operations

In application of robots in harvesting of agricultural and horticultural crops, a common problem is the occurrence of overlapping objects in a scene. Typically, a partially obscured object must be conclusively identified and extracted before it can be picked by the robot. Morphological operations can be used to smooth edges of a region, force shapes onto region edges, count regions and estimate the size of regions. Morphological operators typically use set theories of intersection and union. The case of separating overlapping flowers is presented in this paper. Thresholding, followed by sequential erosion and dilation were successfully applied to separate overlapping flowers in a series of images.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation

To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20cm with interquartile range [IQR] 18-21cm vs 20cm with IQR 18-20cm respectively, P=.4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P<.001) and older age (OR 1.04 with IQR 1.01-1.06, P=.007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

(484) Single Dilation in Primary Inflatable Penile Prosthesis Placement is Associated with Less Corporal Complications than Sequential Dilation

Abstract Introduction In primary implant patients without significant corporal fibrosis, penile implant surgical technique varies in implementation of either single dilation (SingD) or sequential dilation (SeqD). Vigorous debate exists regarding both methods, but there is no robust evidence supporting one technique over the other in the literature. Objective We compared the rates of intraoperative complications and postoperative outcomes from a large international database of inflatable penile prostheses (IPP) performed by expert implant surgeons to determine if there were any significant differences in rates between SingD and SeqD. Methods We analyzed IPP cases performed by international implanters from 2016-2021. All primary implant cases were included, while revision cases, salvage operations, and patients with evidence of corporal fibrosis were excluded. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. These included proximal/distal perforation and cylinder crossover. Results After exclusion based on aforementioned criteria, we identified 3045 patients who underwent IPP. After 1:1 propensity matching of both groups, we analyzed 572 patients who underwent SingD and 572 patients who underwent SeqD. Between the two groups, more men of non-Caucasian race underwent SingD vs SeqD (p&amp;lt;0.001). There was a significant difference in cylinder length in the SeqD group vs the SingD group (20cm ± 1.5 vs. 20 cm ±2 respectively, p=0.018). There were 8 (0.7%) intraoperative complications in total, 7 in the SeqD group and 1 in the SingD group (p=0.034). Of these intraoperative complications, 3 (37.5%) patients who underwent SeqD sustained a proximal perforation, 3 (37.5%) sustained distal crossover, and 1 (12.5%) sustained proximal crossover. 1 patient (12.5%) with intraoperative complication who underwent SingD sustained a proximal perforation. Postoperatively, 78 (82%) of complications were in the SeqD group and 17 (18%) in the SingD group (p&amp;lt;0.001). Of these postoperative complications, there were 15 patients with bleeding or hematoma, of which 14 were in the SeqD group vs 1 in the SingD group (p&amp;lt;0.001). Of the 35 patients who were noted to have device-related malfunction, 29 underwent SeqD and 6 underwent SingD (p&amp;lt;0.001). Postoperative complications were more related to technical error in the SeqD vs the SingD group (11 patients and 1 patient respectively, p&amp;lt;0.011). On multivariate analysis, prior radical prostatectomy was predictive of intraoperative complications (OR 4.59 with IQR 1.39-15.16, p=0.024), while larger cylinder size seemed to be protective (OR 0.66 with IQR 0.50-0.89, p=0.006). On multivariate analysis, SeqD was predictive of postoperative complications (5.16 with IQR 3.01-8.83, p&amp;lt;0.001), as was history of priapism (4.15 with IQR 1.30-13.29, p=0.017). Patients who undergo SeqD may be calibrated by the surgeon to have more complex corpora, which could explain higher complication rates. We identified 3045 patients who underwent IPP. Conclusions In our international multicenter assessment of primary IPPs without corporal fibrosis performed by expert surgeons, patients undergoing single dilation appear to have slight benefit in total cylinder length. Sequential dilation may confer greater risk of intraoperative and postoperative complications, including bleeding and hematoma. Single dilation is a safe technique for primary inflatable penile prosthesis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific

(516) Maximizing Penile Prosthesis Length: Our Technique and Outcomes

Abstract Introduction The most common cause of patient regret after penile prosthesis surgery is penile shortening, which has been reported in up to 70% of patients postoperatively. Objective We sought to query a national database on average prosthesis length and describe our techniques to maximize cylinder sizes. Methods We performed a retrospective review of the Coloplast database of 3-piece penile prosthesis cases performed over the span of 1 year nationally and by a single high volume surgeon and compared average cylinder lengths. Results Between July 1, 2021 and June 27, 2022, 145 three piece penile prosthesis surgeries were performed at our institution. All were performed via a scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed scrotal. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. (Table 1). Our technique to maximize cylinder length involves circumferential mobilization of the corporal bodies and corporal tissue sparing. After initial scrotal incision and dissection to the level of the penile compartment, circumferential mobilization of the corporal bodies is carried out. In addition, the ventral corporal dartos layer is meticulously peeled away. Corporal tissue sparing is carried out by employing 9” Metzenbaum scissors rather than sequential dilators for corporal tunneling. (Image 1). The benefit of this approach is the ability to create a dorsal compartment to the level of the triangular ligament of the glans, thereby extending the space to the level of the midglans. This maneuver minimizes placement of the prosthesis anteriorly at the level of the fossa navicularis and prevents floppy glans that would otherwise compromise maximum cylinder length. Conclusions Three piece penile prosthesis cylinder size can be maximized by circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and the utilization of long Metzenbaum scissors for precise corporal tunneling, ensuring the distal cylinder tips are seated within the tip of the glans rather than at the coronal sulcus. This can help mitigate patient regret after prosthesis surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR

You have accessJournal of UrologyCME1 Apr 2023MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR Amanda McCormac, Minh-Chau Vu, Andrew S. Afyouni, Zachary E. Tano, Sohrab N. Ali, Pengbo Jiang, Roshan M. Patel, Michael Klopfer, Jaime Landman, and Ralph V. Clayman Amanda McCormacAmanda McCormac More articles by this author , Minh-Chau VuMinh-Chau Vu More articles by this author , Andrew S. AfyouniAndrew S. Afyouni More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Sohrab N. AliSohrab N. Ali More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Michael KlopferMichael Klopfer More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior clinical studies, using a novel UCI ureteral access sheath (UAS) force sensor have indicated that passage of a ureteral access sheath at <6 Newtons (N) results in no harm to the ureter. Armed with this information, we sought to define, for the first time, the natural distensibility of the human ureter using sequential urethral dilators in combination with the UCI force sensor while limiting the applied force to 6 N. METHODS: Seventy-five patients (46 females and 29 males) undergoing either ureteroscopy and/or percutaneous stone removal underwent ureteral sizing by passing a series of 35 cm long, urethral dilators in 2 Fr increments within the pre-defined force threshold limit of <6 N. After 6 N was attained, the size of the urethral dilator was recorded and then ureteroscopy was performed and a post-ureteroscopic lesion scale (PULS) was determined. Next, a similar sized UAS, up to 16 Fr was inserted as part of the planned procedure. A multivariable logistic regression analysis was performed assessing the impact of age, gender, tamsulosin, stents, and the combination of tamsulosin and stents on the ability to pass dilators >16 Fr. RESULTS: Among 75 patients, urethral dilators were successfully passed at the 6 N threshold in 37.3% at ≤12 Fr, 24% at 14 Fr, 24% at 16 Fr, and 14.6% at >18 Fr (18-24 Fr). The mean maximum dilator diameter was 14 Fr. Logistic regression revealed that preprocedural ureteral stenting favored passage of >16 Fr dilators (OR 15.47, 95% CI 1.44 – 166.86; p=0.024). Neither gender nor age were significant differentiators. The effect of tamsulosin alone was not statistically significant (OR 0.60, 95% CI 0.15 – 2.32; p=0.454). The interaction effect was not significant suggesting that the effect of stent plus tamsulosin did not differ from stent alone (OR for interaction = 1.85, range 0.089 – 38.63; p=0.690). CONCLUSIONS: The unstented human ureter can be safely sized to an average circumference of 14Fr; this increases to 16 Fr in the prestented ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e468 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda McCormac More articles by this author Minh-Chau Vu More articles by this author Andrew S. Afyouni More articles by this author Zachary E. Tano More articles by this author Sohrab N. Ali More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Michael Klopfer More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

“Rule of Five” in Ureteral Dilatation and its Role in Ureteral Access Sheath Placement during Retrograde Intrarenal Surgery

Purpose: Sequential ureteral dilatation facilitates placement of ureteral access sheath during retrograde intrarenal surgery. The authors adopted some improvisations in conventional sequential ureteral dilatation methods to achieve improved ureteral accommodation and prefer to call the sequential ureteral dilatation performed with these improvisations as “Rule of five” (ROF) ureteral dilatation. The objective of the article was to describe the “ROF” ureteral dilatation technique and share the preliminary experience with the technique. Materials and Methods: “ROF” ureteral dilatation involves repetitive dilatation of ureter for five times by 10 Fr ureteral dilator, with each dilatation lasting for 5 s. The technique was used in patients who underwent retrograde intrarenal surgery for renal calculi and in whom 12 Fr ureteral dilator passage and 9.5/11.5 Fr ureteral access sheath placement was not possible by conventional sequential ureteral dilatation methods. Preliminary efficacy and safety outcomes were reported. Results: “ROF” ureteral dilatation was performed in 14 renal units. Ureteral access sheath placement was successful in 10 renal units (71.4%) and unsuccessful in 4 renal units (28.6%). Ureteral access sheath associated low-grade ureteral wall injury was noted in 2 renal units (14.3%). None had new onset hydroureteronephrosis in follow-up ultrasonography and all patients were asymptomatic in the follow-up period. Conclusion: “ROF” ureteral dilatation is an improvisation of conventional sequential ureteral dilatation. It facilitates successful and safe ureteral access sheath placement in a proportion of patients undergoing sequential ureteral dilatation.

The feasibility and safety of one-shot dilatation compared to conventional sequential dilatation in tubeless percutaneous nephrolithotomy: a prospective randomized controlled study

To study the feasibility and safety of One-Shot Dilatation (OSD), versus serial sequential dilatation in tubeless Percutaneous Nephrolithotomy (PCNL). One Hundred and Fifty patients were randomised into two groups; Group A (One-Shot Dilatation), Group B (Serial Dilatation). Twenty-one patients were excluded from the study. Detailed history was taken and full physical examination was performed. Pre-operative routine laboratory investigations were done. Also, non-contrast Computed Tomography of the Urinary Tract (CTUT) and plain urinary tract x-ray were done. Intra-operative assessments of dilatation, total operative, total fluoroscopy and fluoroscopy during dilatation durations were recorded, as well as estimated blood loss. Post-operatively haemoglobin, creatinine levels and CTUT were performed for all patients. Complications, as urinary leakage time, analgesic requirements and hospitalization time were measured. There were statistically significant differences in the intraoperative durations, where Group A had shorter dilatation time, fluoroscopy time during dilatation and total operative time. Group B had a higher complications rate than Group A; 37.9%, 11.3%, respectively. Also, Group B showed haemoglobin drop by 0.44 mg/dl higher than Group A. More doses of analgesia were required for Group B. Hospitalization time and rate of urinary leakage were both in favour of Group A. For patients undergoing Tubeless PCNL, we have concluded that one-shot dilatation seems to be a safer and more feasible technique than Serial dilatation.

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin's triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin's triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

S1833 Single Operator Cholangioscopy in a Patient With Pancreaticoduodenectomy

Introduction: Cholangioscopy in patients with surgically altered anatomy can be technically challenging. In most patients with pancreaticoduodenectomy undergoing single operator cholangioscopy, the most common approach is through a percutaneous biliary drain placed by interventional radiology. We present a case in which a modified therapeutic upper endoscope (1T scope) was used for single operator cholangioscopy in a patient with pancreaticoduodenectomy. Case Description/Methods: A 64-year-old female with Gardner syndrome requiring colectomy and classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presented for surveillance endoscopy. She previously underwent endoscopic mucosal resection and intraductal radiofrequency ablation (RFA) of adenomatous tissue at the hepaticojejunal (HJ) anastomosis. She subsequently developed a stricture at the HJ anastomosis needing sequential dilations. A 1T scope was used and advanced to the HJ anastomosis. After balloon dilation of the HJ anastomotic stricture, cholangioscopy was performed and revealed abnormal biliary mucosa (Figure) approximately 2 cm below the hilum raising concern for intraductal extension of adenomatous tissue. Cholangioscopy directed biopsies were obtained and pathology revealed tubular adenoma without high-grade dysplasia. Intraductal RFA is planned in the future. Discussion: ERCP in patients with pancreaticoduodenectomy can be challenging. Different endoscopes have been used to overcome some challenges of ERCP in altered anatomy, each offering certain advantages and limitations. Commonly used endoscopes for ERCP in patients with pancreaticoduodenectomy include the adult and pediatric colonoscopes and single balloon enteroscope. These endoscopes do not allow for performing single operator cholangioscopy due to the length of the scope or the width of the accessory channel. Our report highlights that the 1T endoscope allows for performing single operator cholangioscopy in patients with prior pancreaticoduodenectomy when the HJ anastomosis can be reached.Figure 1.: Intraductal extension of adenomatous tissue seen on cholangioscopy.