Single-stage Procedure Research Articles

Revision Clitorolabiaplasty and Urethroplasty After Gender-Affirming Vaginoplasty

ABSTRACT Introduction Gender-affirming vaginoplasty was historically a two-stage procedure with secondary labiaplasty after the initial vaginoplasty. Techniques have evolved into what is now generally a single stage procedure, however some patients may still require revision surgery for cosmetic or functional reasons. Additionally, as with any urethral procedure, patients may develop issues with their urinary stream requiring repeat surgery. Objective The patient is a 51-year-old transgender woman. She underwent robotic-assisted peritoneal flap vaginoplasty in the summer of 2020. Her post-operative course was complicated by recurrent infections. Once the infections had settled and the surgical site was well healed, she had persistent complaints of flat labia majora, overly exposed clitoris causing hypersensitivity, as well as spraying of her urinary stream. We aimed to demonstrate that minor revisions with urethroplasty to relocate the urethral meatus inferiorly as well as securing the clitoris in a more inferior position and bringing the labia together in the midline can provide coverage for the clitoris, more aesthetic appearance of the vulva, and an excellent functional outcome. Methods We first performed the urethroplasty. We began with cystoscopy to identify the level of the external sphincter which was marked externally on the skin. We then incised the skin in the midline starting at the level of the current urethral meatus and extending inferiorly for approximately 2cm. Skin flaps were mobilized off of the urethra bilaterally. The urethra was spatulated ventrally for approximately 1.5cm. The edges were oversewn with 3-0 Vicryl for hemostasis. The superior part of the spatulated urethra was sutured to the surrounding skin to form the lower edge of the vestibulum and provide further definition to the labia minora. The lower edge of the spatulation was sutured to the surrounding skin to become the new urethral meatus. We then turned our attention to the clitoroplasty and labiaplasty. The patient's clitoris was sitting high, over-exposed, and somewhat prolapsed after her initial vaginoplasty and post-operative infections. We started by making a circumferential degloving incision at the level of the glans clitoris. The skin was then carefully mobilized off of the clitoris. A midline incision was made inferior to the clitoris and the clitoris was secured to the vestibulum. A double Z-plasty was performed, in order to bring the labia majora together in the midline to provide better coverage for the clitoris. Results The procedure lasted 4 hours. There was minimal bleeding and no intra- / post-operative complications were encountered. She was discharged home on post-operative day one in good condition. The Foley catheter was left in place until post-operative day five. One month post-operatively, the patient reported resolution of urinary spraying, improved cosmesis, and better coverage for the clitoris. Conclusions Patients may not be satisfied with the cosmetic and functional results following gender-affirming vaginoplasty even if the vaginal canal itself is of adequate dimensions. Minor revisions can provide significant rewards in terms of improvements to the cosmetic appearance of vulva and lower urinary tract symptoms. Disclosure No

Incidental Large Pelvic Schwannoma Found on Rectal Cancer Staging

We present the case of a 53-year-old man with newly diagnosed stage III rectal cancer who was found to have an incidental large pelvic schwannoma on staging imaging. Open enucleation and resection of the 11-cm schwannoma was performed to facilitate our oncologic resection, allowing for a single-stage procedure. Number of similar cases published: three.

Revision Amputation with Press-Fit Osseointegration for Transfemoral Amputees.

We demonstrate the fundamentals of a single-stage procedure involving an impacted press-fit porous-coated titanium osseointegration implant. The preoperative evaluation is summarized and the specific surgical steps are described: exposure, osteotomy, canal preparation, implant insertion, (optional) targeted muscle reinnervation, muscle closure, soft-tissue contouring and stoma creation, and abutment insertion. Amputees who are dissatisfied with their quality of life or mobility when using a socket prosthesis can attempt to modify their socket or activity level or accept their situation. Non-osseointegration surgical options to try to improve socket fit include bone lengthening and/or soft-tissue contouring. An alternative design is a screw-type osseointegration implant1. Press-fit osseointegration can be provided for amputees having difficulty with socket wear5. Press-fit osseointegration usually provides superior mobility and quality of life compared with nonoperative and other operative options for patients expressing dissatisfaction for reasons such as those mentioned above, including poor fit, compromised energy transfer, skin pinching, compression, and abrasions. Review articles describing the clinical outcomes of osseointegration consistently suggest that patients have improved prosthesis wear time, mobility, and quality of life compared with patients with a socket prosthesis3,4. In a recent study2 of 18 femoral and 13 tibial amputees who had osseointegration, Reif et al. showed significant improvements in prosthesis wear time, mobility, and multiple quality-of-life surveys at a mean follow-up of nearly 2 years. The most common postoperative complication for this procedure is low-grade soft-tissue infection, which is usually managed by a short course of oral antibiotics. Much less often, soft-tissue debridement or implant removal may be needed to manage infection. Periprosthetic fractures can nearly always be managed with familiar fracture fixation techniques and implant retention6. Template and choose an implant with an optimal diameter that encroaches the inner cortex at the narrowest bone diameter; an implant that is too wide may not fit without causing a large fracture, and an implant that is too narrow may fall out. Do not cement the implant7.Ideally, the abutment of the implant should rest against a flat transverse bone end with cortical contact and leave the correct amount of room for the prosthetic knee so that it matches the height of the contralateral knee; avoid inserting an implant too distally or in too wide a metaphyseal flare.Gentle impaction pressure is necessary and small contained distal fractures are acceptable, but avoid causing a propagating fracture. Do not place cerclage cables or loose bone graft at these small fracture sites.Avoid the use of a tourniquet during intramedullary reaming to prevent potential heat-induced osteonecrosis.Nerve surgery such as targeted muscle reinnervation, if indicated, can be performed in the same surgical episode as the osseointegration.The muscles should be closed at the bone-implant interface with use of a tight purse string in order to provide a vascularized tissue barrier against bacterial ingress8.The skin surrounding the stoma should have unnecessary fat removed, but not excess removal leading to skin necrosis. The skin fascia should be sutured to the muscle surrounding the stoma to stabilize the peri-stomal skin.Soft-tissue contouring is needed to achieve the optimal soft-tissue tension around the stoma and abutment. Single-stage surgery has a distinct advantage in this regard. MVA = motor vehicle accidentAP = anteroposteriorCT = computed tomographyTMR = targeted muscle reinnervationQTFA = Questionnaire for Persons with a Transfemoral AmputationEQ-5D = EuroQol 5 DimensionsLD-SRS = Limb Deformity-Scoliosis Research Society (questionnaire)PROMIS = Patient-Reported Outcomes Measurement Information System.

Nipple-sparing mastectomy with immediate breast reconstruction with a deep inferior epigastric perforator flap without skin paddle using delayed primary retention suture.

This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics. Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups. Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 monthsof follow-up, the Breast-Q "Satisfaction with surgeon" domain was significant in Group B (p = 0.04). At a mean 12 monthsof follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04). The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.

Single-stage sampling procedure for heteroscedasticity in multiple comparisons with a control

Given k (≥2) independent and normally distributed populations with unknown means and unknown (and possibly unequal) variances, we used the single-stage sampling procedure for multiple comparison with a control to the problem of unequal sample sizes. A simulation of the family-wise error type I was conducted to validate the quality of the procedure and a numerical example was provided for illustrating this procedure. We provided a user-friendly interface by R shiny to obtain the critical values for the practitioners.

Hirschsprung disease managed with one-stage transanal endorectal pullthrough in a low-resource setting without frozen section

BackgroundOver the past few decades, surgery for Hirschsprung’s disease (HD) has evolved into a minimally invasive, single-stage procedure with excellent outcomes. Intraoperative frozen section biopsy is critical for this procedure to avoid the potential risk of leaving a retained aganglionic segment. However, this facility is not available in most low-income countries. Therefore, a two-stage procedure with an initial colostomy is still practiced in the developing world. We aimed to evaluate the outcome of single-stage transanal pullthrough performed in a facility without frozen section biopsy.MethodsA retrospective review of all patients who underwent transanal pullthrough in two teaching hospitals over a 6-year period (2015–2020).ResultsForty-seven children underwent transanal endorectal pullthrough (TERPT). Age at surgery ranged from 2 months to 6 years and mean weight was 8.7 kg. Barium enema did not show transition zone in 6 patients (12.8%) while others demonstrated short segment HD. Intraoperatively, the transition zone was visualized in 40 patients (85%). TERPT alone was performed in 35 (74.5%), TERPT with laparotomy to visualize transition zone in 9 (26.7%) and TERPT with transabdominal mobilization was required in 3 (6.4%). Definitive histopathologic examination revealed aganglionic segment pullthrough in 4 (8.5%) and transitional zone pullthrough in another 4 (8.5%). However, with long term follow up all eight children remained asymptomatic and no intervention was required.ConclusionsTransanal pullthrough offers reduced number of surgeries and faster recovery. We have also observed a good functional outcome despite a discrepancy with pathology results. Overall, our data suggests it is a safe and viable option for the treatment of short segment HD in facilities where frozen section is not available.

Pelvic and inguinal single-site approach: PISA technique. New minimally invasive technique for lymph node dissection in penile cancer

ObjectivesTo describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique. Material and methods10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015–2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. Variables: 30-day PCs, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics. ResultsInguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120–170 min and median EBL was 66 (30–100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications-symptomatic inguinal lymphocele). Median LOS was 5.8 (3–10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25 (8–14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills. ConclusionsPISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Trans-fistula Anorectoplasty (TFARP) in the Management of Anorectal Malformation (ARM) with Recto Vestibular Fistula (RVF) in Females: A Retrospective Study

Aim: To determine the outcome of trans-fistula anorectoplasty (TFARP) in female children having anorectal malformation with recto-vestibular fistula.
 Study Design: A retrospective study.
 Place and Duration: Department of pediatric surgery during the period of February 2018 to February 2020.
 Methodology: A total of 87 female children who have imperforate anus with recto-vestibular fistula from the age of 3 months to 6 years were included in this study. Initially, we have started this technique with the covering sigmoid colostomy, then TFARP after 12 weeks interval & once new anus healed and hegar dilatation achieved then sigmoid colostomy closed after 24 weeks of the first procedure. When we were experienced then we start TFARP as a single-stage procedure. Post-operative data regarding early complications of local wound infections, prolapse of the rectal mucosa, and late complications for anal stenosis, rectal prolapse, and scarring in the perineal body were collected up to 2-3 months respectively.
 Results: A total of 87 patients were included in this study. The average operative time was 40 minutes. The total days of hospital stay were 3 to 5 days. Regarding early complications, skin excoriation was present in 21 (24%) followed by vaginal tear in 17 (19%) cases. Mucosal prolapse was a late complication observed in 17 (20%) cases. Continence was good (Score 0) in 33 (38%) cases, while it was fair (score 1) in 36 (41%) cases.
 Conclusion: Primary repair of recto-vestibular fistula by Trans-fistula anorectoplasty in children is a feasible procedure that has a good cosmetic appearance and anal continence. Single-stage reconstruction is possible in children with satisfactory results. It produces less morbidity and is a more efficient procedure.

Long-Term Complications and Patient-Reported Outcomes After Alloplastic Breast Reconstruction.

The most widely used method for breast reconstruction in Taiwan is alloplastic breast reconstruction, and traditionally, it can be categorized into immediate or delayed, single-stage or 2-stage procedures. We evaluated clinical outcomes and analyzed patients' self-reported satisfaction and quality of life after alloplastic breast reconstruction based on a previous preliminary study. The patients who underwent primary alloplastic breast reconstruction after mastectomy were recruited in 2006 to 2020 at a single institute in Taiwan. The assessment of clinical outcomes was conducted by retrospective chart review and risk analysis. The patients also completed the BREAST-Q, a condition-specific patient-reported outcome measure, at least 6 months after treatment. A total of 237 patients with 247 reconstructed breasts were enrolled in this study. The demographics showed that 205 (83%) were reconstructed using a 2-stage tissue expander-based procedure and 42 (17%) were 1-stage direct-to-implant reconstructions. The mean follow-up time was 79.5 months. The clinical assessment revealed that the overall complication rate was 34%, with infection being the most common (21 patients; 8%). According to risk analysis, smoking (odds ratio, 7.626; 95% confidence interval, 1.56-37.30; P = 0.012), and nipple-sparing mastectomy (odds ratio, 3.281; 95% confidence interval, 1.54-6.99; P = 0.002) were significant risk factors for overall complications. The questionnaire response rate was 38% (94 of 247), at least 6 months after treatment. The total mean score was 69.78. At a single institute in Taiwan from 2006 to 2020, alloplastic breast reconstruction, either single- or 2-stage, have acceptable complication rate and good postoperative satisfaction based on patient-reported outcomes. Both patient- and surgery-related factors presented as significant risk factors. Precise patient selection and comprehensive discussion between the patient and physician may play the important role to achieve optimal aesthetic outcomes.

Improvement of antibacterial activity of Ag-poly(vinyl-alcohol)/chitosan hydrogel by optimizing the procedure of radiolytic synthesis

Hydrogels consisting of radiation-degraded chitosan, poly(vinyl alcohol), and Ag nano-filler, were prepared by γ-irradiation in two-stage and single-stage procedures to examine the role of the synthesis procedure in improving the antibacterial activity. The light scattering method showed that radiation-degradation of chitosan occurred both by breaking the glucoside bonds and by Maillard's reaction. Elemental analysis indicated a reduction in the degree of deacetylation after degradation. The product of Amadori rearrangement and pigmented product melanoidins were determined by 1H NMR, FTIR, UV–Vis, and fluorescence spectroscopy. Enhancement of in vitro antibacterial activity of nanocomposites against Staphylococcus aureus and Escherichia coli was achieved by a single-stage procedure which results in greater mobility of radiation-modified chitosan in the network. This allows the exploitation of its potential, which is reflected in the possibility of the complexing of ultrasmall molecular Ag clusters. These complexes have a considerably stronger antibacterial effect. Ag in molecular form was confirmed by XPS analysis.

PMMA-Cement-PLIF Is Safe and Effective as a Single-Stage Posterior Procedure in Treating Pyogenic Erosive Lumbar Spondylodiscitis-A Single-Center Retrospective Study of 73 Cases.

Background: Surgical treatment for erosive pyogenic spondylodiscitis of the lumbar spine is challenging as, following debridement of the intervertebral and bony abscess, a large and irregular defect is created. Sufficient defect reconstruction with conventional implants using a posterior approach is often impossible. Therefore, we developed the “Cement-PLIF”, a single-stage posterior lumbar procedure, combining posterior lumbar interbody fusion (PLIF) with defect-filling using antibiotic-loaded polymethylmethacrylate (PMMA). This study first describes and evaluates the procedure’s efficacy, safety, and infection eradication rate. Radiological implant stability, bone-regeneration, sagittal profile reconstruction, procedure-related complications, and pre-existing comorbidities were further analyzed. Methods: A retrospective cohort study analyzing 73 consecutive patients with a minimum of a one-year follow-up from 2000–2017. Patient-reported pain levels and improvement in infectious serological parameters evaluated the clinical outcome. Sagittal profile reconstruction, anterior bone-regeneration, and posterior fusion were analyzed in a.p. and lateral radiographs. A Kaplan–Meier analysis was used to determine the impact of pre-existing comorbidities on mortality. Pre-existing comorbidities were quantified using the Charlson-Comorbidity Index (CCI). Results: Mean follow-up was 3.3 (range: 1–16; ±3.2) years. There was no evidence of infection persistence in all patients at the one-year follow-up. One patient underwent revision surgery for early local infection recurrence (1.4%). Five (6.9%) patients required an early secondary intervention at the same level due to minor complications. Radiological follow-up revealed implant stability in 70/73 (95.9%) cases. Successful sagittal reconstruction was demonstrated in all patients (p < 0.001). There was a significant correlation between Kaplan–Meier survival and the number of pre-existing comorbidities (24-months-survival: CCI ≤ 3: 100%; CCI ≥ 3: 84.6%; p = 0.005). Conclusions: The Cement-PLIF procedure for pyogenic erosive spondylodiscitis is an effective and safe treatment as evaluated by infection elimination, clinical outcome, restoration, and maintenance of stability and sagittal alignment.

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures-A Retrospective Analysis from Two Centers.

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012–2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients’ segmental kyphosis and VAS improved significantly, while the KPS remained stable.

Isolated Osteochondral Autograft Versus Allograft Transplantation for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Systematic Review and Meta-analysis

Background: Focal cartilage lesions of the knee remain a difficult entity to treat. Current treatment options include arthroscopic debridement, microfracture, autograft or allograft osteochondral transplantation, and cell-based therapies such as autologous chondrocyte transplantation. Osteochondral transplantation techniques restore the normal topography of the condyles and provide mature hyaline cartilage in a single-stage procedure. However, clinical outcomes comparing autograft versus allograft techniques are scarce. Purpose: To perform a comprehensive systematic review and meta-analysis of high-quality studies to evaluate the results of osteochondral autograft and allograft transplantation for the treatment of symptomatic cartilage defects of the knee. Study Design: Systematic review and meta-analysis; Level of evidence, 2. Methods: A comprehensive search of the literature was conducted using various databases. Inclusion criteria were level 1 or 2 original studies, studies with patients reporting knee cartilage injuries and chondral defects, mean follow-up ≥2 years, and studies focusing on osteochondral transplant techniques. Exclusion criteria were studies with nonknee chondral defects, studies reporting clinical outcomes of osteochondral autograft or allograft combined with other procedures, animal studies, cadaveric studies, non–English language studies, case reports, and reviews or editorials. Primary outcomes included patient-reported outcomes and failure rates associated with both techniques, and factors such as lesion size, age, sex, and the number of plugs transplanted were assessed. Metaregression using a mixed-effects model was utilized for meta-analyses. Results: The search resulted in 20 included studies with 364 cases of osteochondral autograft and 272 cases of osteochondral allograft. Mean postoperative survival was 88.2% in the osteochondral autograft cohort as compared with 87.2% in the osteochondral allograft cohort at 5.4 and 5.2 years, respectively (P = .6605). Patient-reported outcomes improved by an average of 65.1% and 81.1% after osteochondral autograft and allograft, respectively (P = .0001). However, meta-analysis revealed no significant difference in patient-reported outcome percentage change between osteochondral autograft and allograft (P = .97) and a coefficient of 0.033 (95% CI, –1.91 to 1.98). Meta-analysis of the relative risk of graft failure after osteochondral autograft versus allograft showed no significant differences (P = .66) and a coefficient of 0.114 (95% CI, –0.46 to 0.69). Furthermore, the regression did not find other predictors (mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location) that may have significantly affected patient-reported outcome percentage change or postoperative failure between osteochondral autograft versus allograft. Conclusion: Osteochondral autograft and allograft result in favorable patient-reported outcomes and graft survival rates at medium-term follow-up. While predictors for outcomes such as mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location did not affect the comparison of the 2 cohorts, proper patient selection for either procedure remains paramount to the success and potentially long-term viability of the graft.

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Técnica PISA: nueva técnica mínimamente invasiva de acceso único para la linfadenectomía pélvica e inguinal en el cáncer de pene

ObjectivesTo describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique. Material and Methods10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. Variables: 30-day postoperative complicactions, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics. ResultsInguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170minutes and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications- symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25(8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills. ConclusionsPISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Update on surgical management of enteroatmospheric fistulae in intestinal failure patients.

The surgical management of enteroatmospheric fistula (EAF) in patients with intestinal failure represents a major challenge for a surgical team and requires proficiency in sepsis management, nutritional support and prehabilitation, beside expertise in visceral and abdominal wall surgery. This review provides an update on the current recommendations and evidence. Reconstructive surgery should be performed at a minimum of 6-12 months after last laparotomy. Isolation techniques and new occlusion devices may accelerate spontaneous EAF closure in selected cases. Chyme reinfusion supports enteral and parenteral nutrition. Stapler anastomosis and failure to close the fascia increase the risk of EAF recurrence. Posterior component separation, intraoperative fascial tension and biological meshes may be used to accommodate fascial closure. Timing of reconstructive surgery and previous optimal conservative treatment is vital for favorable outcomes. Wound conditions, nutritional support and general patient status should be optimal before attempting a definitive fistula takedown. Single stage procedures with autologous gut reconstruction and abdominal wall reconstruction can be complex but well tolerated.

Post - Excisional Defect of Middle Third of Helix Reconstructed by Antia-Buch Helical Chondrocutaneous Advancement Flap

The Antia-Buch flap is a chondrocutaneous helical advancement flap done as a single stage procedure to reconstruct the helix. Here, we present a 62 year old male patient with basal cell carcinoma of the middle 3rd of the helix of the left pinna. He underwent local excision with a 0.5cm margin and the resulting defect was reconstructed with an Antia-Buch chondrocutaneous helical advancement flap.

Single stage versus two-stage orthoplastic management of bone infection

IntroductionBone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. MethodsUsing an existing 2009–2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. ResultsA total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. ConclusionsThe single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.

Laparoscopic Management of Undescended Testis: Results and Outcomes in a Pediatric Population

Aim: This study aimed to evaluate the results of the laparoscopic treatment of high and intra-abdominal undescended testes. Methods: A retrospective study was carried out from 2014 to 2021 at the Centre medico-chirugicale d’urologie in Douala. We consulted the clinical records of 27 patients aged 6 - 15 years who underwent laparoscopic orchiopexy at our hospital. We included patients with unilateral or bilateral undescended testes as detected by palpation and excluded patients with incomplete clinical records. The data collected were entered into Microsoft Excel 2016 and exported to Epi info 7 for analysis. Continuous variables were presented as mean values and standard deviations while categorical variables were presented as frequencies and percentages. The threshold for statistical significance was set at p Results: The ages of the 27 participants ranged from 6 years to 15 years, with a mean age of 10.22 ± 2.68 years. Hypospadias was an associated abnormality in 7.41% of participants. The mean duration of the surgical procedure was 80.56 ± 30.30 minutes. The overall success rate of the laparoscopic procedure was 95.83%. The mean duration of postoperative hospital stay was 26.67 ± 7.69 hours. The only postoperative complication we encountered was testicular atrophy, which occurred in 7.41% of participants. All our patients underwent single-stage laparoscopic procedures. Conclusion: Laparoscopy, which is the technique of choice for the diagnosis and management of undescended testis, is more rapid, more effective, and characterized by a shorter hospital stay and fewer postoperative complications compared to open surgery. Single-stage procedures are as effective and safe as two-stage procedures.

Extended Ulaanbaatar Procedure with Preputial Skin Graft for Proximal Hypospadias.

Two stage urethroplasty for proximal penile hypospadias is time consuming, expensive and; traumatic both for parents and phallus. On the other hand, single stage procedure technically demanding. We would like to describe Extended Ulaanbaatar Procedure (EUP) which is not a two stage procedure. Rather, might be called as 'extended single stage' procedure. In EUP we have done orthoplasty along with urethroplasty with preputial skin graft at same sitting as primary procedure keeping urination diverted through proximal hypospadiac meatus as "controlled fistula" which was closed after six months as secondary procedure. We operated on 35 patients of proximal penile hypospadias with moderate to severe chordee. Chordee was excised till correction of curvature. Two distracted cut ends of native plate was bridged with preputial skin graft (PSG) in between. Following that, silastic tube was placed over glandular plate as scaffold, on both cut ends of native plate and PSG. All the urethral plates and PSG were buried with tunica vaginalis flap before glanuloplasty. After six months, proximal "controlled fistula" was closed with scrotal dartos fascia and skin to join distal to proximal urethra. Vertical meatus in glans was found in 32 patients. One patient had glans dehiscence, two patients had medium sized fistula, another two patients had stenosis in neourethra and six had suture track fistula. Twenty-nine patients had satisfactory curve with good flow in uroflowmetry as per nomogram at sixth month of follow up. In classic Ulaanbaatar procedure authors do distal urethroplasty and glanuloplsaty in 1st stage following orthoplasty to avoid repeat trauma in glans in repeat procedures. Left over urethroplasty in classic Ulaanbaatar was done in 2nd stage. However, in EUP; we did urethroplasty for full length following orthoplasty as primary procedure. This procedure is less invasive than two staged as we avoided repeat degloving and repeat dissection on operated tissues. Urethroplasty done as primary procedure shunned the need of repeat degloving, decreased the period of morbidity, stay, and cost of surgery. We also avoided problems of urination through not matured, long, neo-urethra. Similarly complications i.e disruption, stenosis in neo-urethra can be managed utilizing the advantages of urinary diversion.