Standard Lithotomy Position Research Articles

External pressure at calf region in low lithotomy position is higher in men and increases proportionately with height, weight, lower leg size, and foot length

ObjectivePatients placed in lithotomy position (LP) with a leg holder during surgical procedures have been at particular risk of developing well leg compartment syndrome (WLCS). A commonly considered contributing factor of WLCS is obesity. LP is mainly divided into the following four types by the degree of hip angulation and height of lower leg placement relative to the heart: low, standard, high, and exaggerated. We have reported that the external pressure at the calf region in standard LP is independent of weight. In the present study, we investigated the relationship between the external pressure in low LP and physical characteristics, such as body, leg, and foot sizes. MethodsFifty-five volunteers, 27 men and 28 women, participated in this study. They were placed in low LP with the boot-support-type leg holder, with the hip joints flexed at 170° from the trunk and abducted at 45°, and with the knee joints flexed at 120°. Peak contact pressure (PCP) at the calf region was measured as representative external pressure by using the pressure distribution measurement system, BIG-MAT®. ResultsThe mean PCPs at the left and right calf regions in men (37.6 and 39.3 mmHg, respectively) were significantly higher than those in women (31.5 and 33.6 mmHg [P = 0.014 and 0.001], respectively). The left PCPs correlated positively with height (P = 0.003), weight (P = 0.001), body mass index (BMI) (P = 0.037), tibial length (TL) (P < 0.001), bimalleolar breadth (BB) (P = 0.046), maximum calf girth (MCG) (P = 0.035), and foot length (FL) (P = 0.001); and the right PCPs correlated positively with height (P < 0.001), weight (P < 0.001), BMI (P = 0.063), TL (P < 0.001), BB (P = 0.001), MCG (P = 0.005), and FL (P = 0.001). ConclusionThe external pressure at the calf region in low LP is higher in men and increases proportionately with height, weight, lower leg size, and FL, which may contribute to the risks of inducing WLCS during surgeries performed in low LP.

An Innovative Technique of Transurethral Seminal Vesiculoscopy with Ultrasonic Lithotripter for Severe Persistent Hematospermia

Abstract Introduction: To introduce an innovative technique of transurethral seminal vesiculoscopy (TSV) with ultrasonic lithotripter for severe persistent hematospermia. Materials and Methods: From May 2012 to December 2015, totally 14 patients with severe persistent hematospermia underwent TSV with an ultrasonic lithotripter. For the patient with a positive urine solution microorganism culture, the sensitive antimicrobial therapy is administrated and the negative culture outcome is confirmed before the TSV procedure.1,2 Under general anesthesia, the patient is positioned in the standard lithotomy position. The 8F rigid ureteroscopy used as the seminal vesiculoscopy is inserted retrogradely, under the guidance of a 0.032-inch Zebra guidewire, through the utricular orifice at the verumontanum.3 After entering the lumen, the Zebra guidewire is further introduced through the ejaculatory duct orifice to guide the ureteroscopy entering seminal vesicle. If the orifice is masked behind a thin transparent membra...

Guidelines for the Standardization of Genital Photography.

Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery.

Does maternal position during delivery affect the incidence of neonatal shoulder dystocia?

EVIDENCE-BASED ANSWER Apparently not. Although underpowered, studies show that mothers delivering in McRoberts position (flexion and abduction of hips) with or without early suprapubic pressure or alternative positions (such as lateral, handsknees, or squatting) do not have a reduced incidence of shoulder dystocia compared with mothers delivering in the standard lithotomy position (SOR: B, underpowered RCTs, quasi-RCT, and cohort study).

Flexible ureterorenoscopy results: Analysis of 279 cases

In this study, the outcomes of 279 cases in whom we performed retrograde intrarenal surgery (RIRS) were evaluated retrospectively. RIRS was performed on 279 cases with the aid of access sheath of guidewire between March 2011 and February 2015. All patients were operated in the standard lithotomy position. A hydrophilic guidewire was inserted with the aid of rigid ureterorenoscopy and we checked whether there were any residual ureteral stones and other pathologies. Fluoroscopy was used routinely in all cases. Stone fragments smaller than 3 mm were left off but those bigger than 3 mm were removed by grasper after stone fragmentation. Controls of the patients were assessed by plain films (KUB), urinary tract ultrasonography (US) and/or computed tomography (CT) 1 month after the operation. Success rate of the procedure was defined as the stone-free status or presence of residual fragments less than 3 mm. 152 of the patients were male and 127 were female. The median ages of the male and female patients were 47.7 (1-86) ve 45.9 (3-79) years respectively. The median stone size was 13.5 mm (8-25). Preoperatively 34 (12.1%) patients had double-J ureteral stent. 19 (6.8%) patients were operated while they were still receiving antithrombotic and antiplatelet therapy Solitary kidney was present in 24 patients while the remaining patients had kyphoscoliosis (n=3), rotation anomaly (n=6), pelvic kidney (n=2), double collecting system (n=3), and horseshoe kidney (n=6). In 264 patients access sheath was used, in 15 patients operation was performed with the help of the guidewire. Double-J stents were inserted to 14 patients because of ureteral stricture and they underwent operation after 2 weeks later. Renal stones of 219 patients among all cases were fragmented completely and the patients were discharged as stone free (SF). Our success rate (SF or presence of clinically insignificant residual [CIRF]) was 78.4%. Stone size (p=0.029), stone number (p=0.01), stone location (p=0.023) had significant influence on the stone-free rate after RIRS The mean operation and floroscopy time was 62.5 min. (40-180) and 29.8 sec (4-96), respectively. The mean hospitalization time was 26.4 hours (12-72). Double J stents were placed to 253 patients for more stone burden and ureteral edema. Any complication was not observed for all cases except perioperative developed infection for two patients. With advances in laser technology and flexible ureterorenoscopy, kidney stones can be treated with lower morbidity and high success rates.

Combined vagino-abdominal approach for management of vesicovaginal fistulas: a 10 years' experience.

Vesicovaginal fistulas (VVF) are an uncommon but serious complication of gynecological surgery. The aim of this study was to report our experience with the repair of VVF using combined vaginal and extraperitoneal abdominal approaches. Between 2000 and 2012, 15 consecutive females with VVF were managed with combined vaginal and extraperitoneal abdominal procedures. After assessment by voiding cystourethrography and urethrocystoscopy, the operation was performed at the standard lithotomy position. Fifteen patients were included in this study with mean age 51.8 ± 11.9 years. The mean fistula size was 2.1 ± 0.7 cm and all of them were located in supra-trigonal region except one case that fistula defect extend to the bladder trigon. Fourteen patients reported complete resolution of urinary incontinence during mean follow-up of 3.5 years. Fistula was recurred in one female 1 year after repair due to cancer recurrence and radiotherapy treatment. No intraoperative complication including massive bleeding or ureteral damage was observed. Our experience with combined vaginal and extraperitoneal abdominal repair of a vesicovaginal fistula shows its feasibility and safety with good results.

A 12‐year experience of the Trendelenburg perineal approach for abdominoperineal resection

The abdominoperineal resection (APR) is the current accepted surgical technique for low rectal cancers. Negative circumferential surgical margins are an important prognostic indicator and are best obtained by producing a cylindrical specimen. The 'ideal' approach to produce such specimen is debated between a standard lithotomy position and turning the patient in the prone position in the later stages of the procedure. We aimed to assess results of perineal morbidity and oncological outcomes following the lithotomy approach at a single institution. Data were collected retrospectively at a single institution. All patients undergoing the APR for low rectal cancers were included in the current study. Patients underwent this procedure in the standard lithotomy position and a mucocutaneous flap was not routinely used for closure of the perineal wound. The primary outcome measures in this study were local and systemic tumour recurrence and overall patient survival. Fifty-three patients undergoing APR were included in the current study. Majority of patients (87%) received neoadjuvant therapy. Perineal morbidity was observed in 11% of patients loco-regional recurrence occurred in 4% at 5 years. One-, 3- and 5-year survival was 87, 75 and 66%, respectively. Patients with T3/4 disease and positive circumferential surgical margins had significantly poorer survival outcomes. APR can be performed in the lithotomy position with acceptable perineal morbidity and oncological safety. Negative circumferential margins can be achieved reliably by producing a cylindrical specimen with this position.

Laparoendoscopic Single-Port Transvesical Diverticulectomy: Preliminary Clinical Experience

We present our single-center experience with three patients who were undergoing laparoendoscopic single-site (LESS) diverticulectomy through a single-port device introduced directly into the bladder. During March and April 2011, we operated on three men aged 62 to 76 years (mean 67 y) for symptomatic bladder diverticula using a standard lithotomy position and general anesthesia. The procedure was performed transvesically (percutaneous intraluminal approach) with a single-port device (four-channel) via a 1.5-cm incision made 2 cm above the pubic symphysis. Standard 10-mm optic and rigid laparoscopic instruments were used. The defect of the bladder wall was closed with an absorbable 3/0 running V-Loc suture. An 18F Foley catheter was left for 4 to 7 days. The average operative time was 128 minutes (range 80-175 min). The blood loss was minimal. Patients were discharged on the third postoperative day with no intra-, nor postoperative complications. The 3-month follow-up confirmed good operative results in all cases. We consider laparoendoscopic single-port transvesical excision of bladder diverticulum as a feasible and safe procedure and a valuable treatment option for bladder diverticulectomy.

Side Docking the Robot for Robotic Laparoscopic Radical Prostatectomy

Low lithotomy position with the robot between the legs for docking is a standard position for robotic radical prostatectomy. Its complications include occasional nerve injury and compartment syndrome. In some patients with conditions that limit hip abduction, this position may be infeasible. We report a docking technique that obviates stirrups and simplifies setup without altering surgical technique. A total of 100 consecutive patients underwent robotic radical prostatectomy for localized prostate cancer. Fifty patients (group 1) were in the standard lithotomy position, and the remaining 50 patients (group 2) were in slight trendelenburg position with the robot at the side of the bed - "side-docked." Setup and docking times were recorded and both groups were compared for differences in operative variables. Mean setup time for group 2 was 4.7 minutes shorter than for group 1 (p = 0.02). Docking time and other operative variables were statistically similar and not affected by the adoption of side-docking technique. However, overall surgical time was longer due to modifications in other aspects of the technique during the study period. Side-docking for robotic radical prostatectomy is associated with small but significant improvement in setup time and can be utilized in patients with limited hip abduction.

Lithotomy by Empirical Doctors in the 19th Century: a Traditional Surgical Technique That Lasted Through the Centuries

Lithotomy is an ancient surgical procedure, well-known in the history of urology. We describe the method as it was performed by empirical doctors in Greece during the 19th century and compare it to older techniques. The original Greek text of a doctor's autobiography includes a description of a lateral perineal cystotomy performed by empirical doctors in 1818. The technique is compared with that described by Celsus and Byzantine medical writers. A study of the sources revealed that the 2 itinerant doctors who specialized in lithotomy used a lateral perineal cystotomy to remove stones from the bladder. Consent was obtained from the parents of the patient. The patient adopted the standard lithotomy position, the surgeon located the stone with his finger via the anus and immobilized it, and made a lateral perineal incision to remove it. A newly killed fowl was then placed on the wound. The ancient surgical lithotomy technique seems to have been passed on almost unchanged from father to son and has influenced urology in Europe since the time of Celsus (1st century AD) and the Byzantine surgeon Paul of Aegina (7th century AD). Postoperative therapy is similar to that of other Byzantine techniques, and it is interesting that written informed consent was obtained, signed in the presence of witnesses.

Heel and Calf Capillary-Support Pressure in Lithotomy Positions

A three-part analysis was undertaken to increase understanding of the occurrence of pressure ulcers in lithotomy positions. An innovative measuring device was used to determine capillary pressure. Ankle blood pressure was measured compared to ankle height in 11 participants. Ankle systolic and diastolic pressure decreased approximately 20 mmHg per foot of elevation. Calf and heel capillary-support pressures were measured in 15 participants in the standard lithotomy position. Capillary-support pressure for the calf was substantially less than for the heel. Heel capillary-support pressures were measured in 16 participants in the high lithotomy position. As heel height increased, capillary-support pressure also increased.

側射用ファイバーを用いた前立腺レーザー治療

Animal experiment was performed with seven male dogs weighing between 21 and 25 kg, under general anesthesia, with pentobarbital sodium (25mg/kg). A midline lower abdominal incision was made to expose the urinary bladder. 23Fr conventional cystoscope was introduced into the prostatic urethra via cystostomy. The entire operative procedure was observed under TV monitor. Laser irradiation was begun linearly from proximal to the apex of the prostate using Hercules 5060UTM and Model 6000TM Nd: YAG laser (LaserSonics) and UltraLineTM (LaserSonics) fiber which delivered 50 watts of power for 20, 30, 40 and 60 seconds at 3, 9 o'clock. Animals were killed immediately, and at 2, 4, and 6 weeks after the operation. The bladder, prostate and urethra were carefully examined and removed. Specimens were cut into transverse step-section. As the results, thermal coagulation necrosis and delayed sloughing were observed usually several weeks after the procedure. The prostatic urethral cavity was covered with transitional epithelium in the later stage. Clinically 27 male patients underwent laser operation. Their ages ranged from 53 to 80 years of age. The present study selected the patient with below 15 ml/sec in peak flow rate (uroflometry), above 20 gram prostate volume (transrectal ultrasound) and above 15 points in AUA Symptom Score, and excluded the patient with prostatic cancer and neurogenic bladder. The used instrument was the same as those used in the animal experiment. The laser prostatectomy was carried out with standard lithotomy position under spinal anesthesia. The laser was employed at four radial regions (2,4,8 and 10 o'clock positions), additionally to 3,5,7 and 9 o'clock position, with the fiber being dragged from the bladder neck to the verumontanum. The laser was set at 50 watts power on continuous wave. The drag rate was from 30 to 60 seconds. Clinical efficiency was determined by peak flow rate, residual urine, AUA Symptom Score, prostatic volume and side effect. The total evaluation was divided into 3 grades (useful, slightly useful, not useful). According to the criteria, laser surgery was classified as useful in 11 (68.8%). As the side effect, 13 patients revealed urinary retention and one patient showed acute epididymitis after the operation.