Surgeon Patient Research Articles

What Is the Optimal Method of Fixation for Scaphoid Nonunion Relative to the Location of the Lesion?

Scaphoid nonunion is a typical complication of scaphoid fractures, with the nonunion rate varying by the location of the scaphoid. The current widely used method for treating scaphoid nonunion, which is challenging for surgeons, is the headless compression screw (HCS). Various surgical approaches, such as the scaphoid plate, have been proposed to address the problem of screw fixation; however, no consensus exists regarding the optimal treatment method. This study focused on analyzing appropriate treatment methods based on the anatomical location of the scaphoid nonunion. Ninety-seven patients with scaphoid nonunion were treated between 2008 and 2023. All patients underwent treatment using 1 HCS or scaphoid volar locking plate with nonvascularized bone graft from the distal radius depending on the scaphoid's location. The scaphoid angle and bone union were confirmed using radiological examinations. The clinical evaluations included range of motion, pain, grip strength, and functional wrist scores. Fifty-seven patients were included in the final analysis. In the screw group, 26 patients (26/42 [62%]) obtained a bone union, and all 15 patients (15/15 [100%]) in the plate group obtained a union ( P = 0.005). In the waist group, 16 patients with screw (16/25 [64%]) and 8 using a plate (8/8 [100%]) showed bony healing. In the proximal group, 3 patients with HCS (3/9 [33%]) and 4 using plate (4/4 [100%]) showed bone union. In the distal group, 7 patients with a screw (7/8 [87%]) and 3 with the plate (3/3 [100%]) showed bone union. Significant differences were found in the waist ( P = 0.047) and proximal groups ( P = 0.026), but not in the distal group ( P = 0.521). All groups showed improved radiological angles associated with the scaphoid and better clinical outcomes postoperatively. Plate fixation was overall superior to screw fixation for scaphoid nonunion, especially in the waist and proximal poles, providing better union rates and stability. For the distal group, both methods are effective, with the choice depending on the surgeon's expertise and patient factors. The results highlight the importance of the lesion's anatomical location in selecting the appropriate fixation method.

Triple Surgical Technique for the Repair of Auricular Keloids: Achieving Perfect Restoration of the Ear Contour.

Ear keloids, often resulting from ear piercing or other traumas, significantly alter appearance, adversely impacting patients' quality of life and psychological well-being. Thus, developing an effective and esthetically pleasing surgical repair technique is crucial for enhancing patient quality of life. This study introduces a novel tripartite surgical approach, which includes arcuate incision design, blind dissection for scar flap, and centrifugal keloid core serial shave excision (ABC for short). This technique is particularly suited for keloids induced by ear piercing that are inoperable for direct suturing or where direct suturing significantly alters the ear contour. In this study, 17 patients underwent the surgical treatment without observing special complications such as infection or necrosis. Long-term postoperative follow-up demonstrated good restoration of the ear contour, with only one case of recurrence. Patients expressed satisfaction with both the surgical process and outcomes. The triple surgical technique (ABC surgery method) for treating auricular keloids has demonstrated excellent repair results, significantly improving auricle shape. Despite relying on the surgeon's experience, keloid characteristics, and patient comorbidities, it provides an effective treatment option. When combined with local radiotherapy, the recurrence rate is also significantly controlled. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cutting-edge care: unleashing artificial intelligence's potential in gynecologic surgery.

Artificial intelligence (AI) is now integrated in our daily life. It has also been incorporated in medicine with algorithms to diagnose, recommend treatment options, and estimate prognosis. AI in surgery differs from virtual AI used for clinical application. Physical AI in the form of computer vision and augmented reality is used to improve surgeon's skills, performance, and patient outcomes. Several applications of AI and augmented reality are utilized in gynecologic surgery. AI's potential use can be found in all phases of surgery: preoperatively, intra-operatively, and postoperatively. Its current benefits are for improving accuracy, surgeon's precision, and reducing complications.

A longitudinal study examining the relationship between prioritization scores and changes in impact on life scores in elective surgery patients.

Healthcare systems globally face the issue of resource constraints and need for prioritization of elective surgery. Inclusive, explicit prioritization tools are important in improving consistency and equity of access to surgery across health systems. The General Surgical Prioritization Tool developed by New Zealand's Ministry of Health scores patients for elective non-cancer surgery based on surgeon's clinical judgement and patient derived Impact on Life (IoL) scores. This study aims to measure the changes in patient derived IoL scores after common general surgical procedures to enable direct comparison and inform future prioritization. This longitudinal observational study enrolled 322 participants who had undergone elective general surgical procedures. Participants were contacted 3 to 9 months after their procedures and requested to complete the IoL questionnaire. The primary endpoint was the change in IoL scores after surgery among the different procedures. Overall, 229/304 (75%) participants responded to the questionnaire and there were no significant baseline differences between responders and non-responders. Patients in the gallbladder treatment group had the greatest improvement in IoL scores. Patients across all ethnic groups had similar changes in IoL scores. Multivariate analysis showed that gallbladder surgery (relative to hernia surgery) and pre-surgery IoL scores significantly predicted improvement. The patient reported IoL score recorded at prioritization for surgery all reduced, albeit to varying amounts, after common general surgical procedures. This, combined with the fact that IoL scores predicted post-operative improvement support their inclusion in prioritization tools in addition to surgeon derived components.

Recovery of subcutaneous orbital fascia under preserved skin below the original crease in the repair of excessively high double-eyelid folds

BackgroundHigh-eyelid fold is a common complication of upper eyelid surgery. This study proposed a novel technique for correcting high-eyelid fold in Asian patients with little eyelid skin and thick orbital fascia to improve cosmetic outcomes and patient satisfaction. MethodsWe retrospectively analysed the clinical data of 38 patients with high-eyelid fold repaired at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, from July 2017 to April 2022. All patients were treated using this method of preserving the high-eyelid fold and reconstructing the subcutaneous orbital fascia. Postoperative outcomes were reviewed and analysed using objective measures and subjective surgeon and patient evaluations. ResultsThirty-eight patients (71 eyes) were included. Postoperative follow-up was for 6–25 months. At 6 months postoperatively, the mean anatomic crease height decreased from 10.45 mm to 6.22 mm, mean pretarsal show decreased from 3.20 mm to 1.61 mm, and mean margin reflex distance in 1 of the 31 patients with ptosis increased from 2.93 mm to 3.87 mm (P < 0.001). The compliance rate between the surgeon's assessment and patient satisfaction was 89.5%, with 31 cases considered good by both the surgeon and patient and one case considered poor by both (undercorrected ptosis), though a satisfactory result was achieved after reoperation. Neither recurrence of the original crease nor serious complications were reported. ConclusionBy preserving high-eyelid folds and reconstructing the subcutaneous orbital fascia, unnaturally high- and deep-eyelid folds were converted to lower, nondepressed folds.

Is it true that treatment in patients with Subaxial Cervical Spine Injury Classification System (SLICS) 4 is the surgeon's choice?

The Subaxial Cervical Spine Injury Classification System (SLICS) is a commonly used algorithm for diagnosing and managing subaxial cervical spine trauma. A SLIC score 4 suggests either surgery or non-surgically treatment depending on the surgeon's experience and patient's conditions. Prognosis and treatment results were analyzed in patients with SLIC score 4. The patients with SLIC score 4 were retrospectively reviewed from 2012 to 2019. Forty-one patients were included and divided into two groups: non-surgically treated and surgically treated. Demographic data and radiographs were analyzed. Statistical analysis was performed to determine the difference between the two clinical groups. Twenty-two patients were non-surgically treated, and nineteen patients were surgically treated. There was no neurological deterioration in both groups. However, there was no statistically significant difference in the last follow-up AISA and Nurick grade (p> 0.05). There was no significant difference in the number of patients who showed improvement when comparing the initial and the last follow-up neurological status (p> 0.05). Regardless of the treatment method, the spinal cord injury patients with SLICS point 4 showed a relatively good prognosis. Patients with SLIC score 4 could be treated non-surgically or surgically based on the surgeon's experience and factors associated with the patient's acute health status and chronic comorbidities.

How to make MIS bunion surgeries easier- it's all about the room set-up: Technical tip

There has been increasing interest and studies reporting the clinical and radiologic outcomes of minimally invasive bunion surgeries (MIS). These studies address how to perform these surgeries, however there are no clear standards or guidance to help surgeons improve and optimize their operating room setup for minimally invasive bunion surgeries unlike other orthopedic procedures.Improving and optimizing operating room setup for MIS bunion surgeries is important to improve surgeon's convenience, patient safety and outcomes and hopefully shorten the learning curve for MIS bunion surgeries.The aim of this paper is to share our experience with what we believe is an improved operating room setup for MIS bunion and forefoot surgeries. This setup might help new MIS surgeons improve their outcomes, decrease the complication rates and shorten the learning curve.

Factors influencing decisions among the public related to the chosen surgeons for elective surgeries: A nationwide study

AimIt is a complex decision for patients and their families to select a qualified surgeon who meets their needs. Understanding these needs enables surgeons to build stronger relationship with patients. This study aimed to identify influencing factors, variables, and criteria that individuals consider when selecting surgeons for elective surgeries. MethodsThis is a nationwide cross-sectional study conducted among patients who have undergone elective surgeries in Saudi Arabia. The data were collected with an anonymous self-administered pre-validated questionnaire. The collection of data was carried out through web-based questionnaires using google forms. The questionnaire contains socio-demographic characteristics (i.e., age, gender, education, etc.) and different factors to assess patients' perceptions in choosing a surgeon. ResultPatients' overall number was 3133 (56.2 % females vs 43.8 % males). The most common age group was 18 to 34 years old (63.7 %). The prevalence of patients who were able to choose the right surgeon to perform an operation was 79.8 %. Patients' top choice when selecting a surgeon was according to the surgeon's manner followed by the qualifications then the reputation. Females are choosing a surgeon according to his/her manner while males are choosing according to his/her qualifications. ConclusionSurgeons' manner and qualifications are the most considered factors among when selecting a surgeon while the realistic factors such as accreditation of a facility and surgeon's scientific roles, quality improvement, and patient safety are ignored among the public. This requires condensed educational efforts and further research to determine the advertisements and social media effects on patients' decisions related to their health.

Intracorporeal colpotomy using the Gutclamper as a novel clamping device to prevent tumor spillage during laparoscopic radical hysterectomy for cervical cancer.

Tumor cell spillage during the colpotomy has been suspected as one reason for poor oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer. To prevent such tumor spillage in LRH, we focused on use of a Gutclamper which is a device originally designed to clamp the colon and rectum during colorectal resections. A woman with stage IB1 cervical cancer underwent LRH using the Gutclamper. The Gutclamper was inserted into the abdominal cavity via 5-mm trocar, the vagina was clamped, and an intracorporeal colpotomy was performed caudal to this device. The Gutclamper can be used to clamp the vaginal canal and avoid the exposure of cervical tumor, regardless of the surgeon's skills or patient conditions. An intracorporeal colpotomy using the Gutclamper can contribute to the standardization of LRH.

Butterfly needle tap and suction (BTS) technique: a treatment for recurrent chronic subdural hematoma after burr hole craniostomy.

In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle. This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications. Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4ml in the BTS-alone group and 49.4 ± 12.9ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein. The BTS technique is an effective alternative to reoperation with BHC.

Endoscopic Removal of Migrated Nissen Fundoplication Mesh

Laparoscopic Nissen fundoplication is known to be a safe and feasible method in the treatment of hiatal hernias. However, a recurrence rate of 42% has been reported. Using mesh repair in patients undergoing Nissen fundoplication has shown fewer recurrence rates than the primary suture, even though there have been few complications reported. Some complications that may occur with mesh placement are; severe fibrosis, esophageal strictures, esophageal perforations, mesh migration to the upper gastrointestinal tract, and mesh erosion in the intestinal wall, etc. In this report, the migration of the leathery esophagus developed after about 11 years was presented. In such cases, patients may have several surgical options. Among these options, the mesh was completely removed endoscopically. No further surgery was required. In conclusion, it is recommended to use a very selective mesh in the laparoscopic repair of the hiatal hernias, considering the surgeon's experience, hiatus anatomy, and patient's symptoms.

Prediction of anterior tibiotalar ligament injury: measurement of the angle between the deep posterior tibiotalar ligament and talus on MRI.

Identification of anterior tibiotalar ligament (aTTL) injury is essential because it influences the surgeon's treatment option and patient prognosis. To assess the diagnostic accuracy of the angle measurement between the talus and posterior tibiotalar ligament (talus-pTTL) on magnetic resonance imaging (MRI) in patients with arthroscopically proven aTTL injuries. Ankle MRI scans of 67 patients who underwent arthroscopic examination were retrospectively reviewed. The talus-pTTL angle on axial T2-weighted MRI and the medial clear space (MCS) on mortise ankle radiograph were measured. Inter-observer agreement of the measurements was calculated. Also, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were the metrics of diagnostic accuracy. AUC was 0.90 for observer 1 with 78.6% sensitivity, 97.4% specificity, 88% accuracy, and 54.7° cutoff value for the talus-pTTL angle. AUC was 0.87 for observer 2 with 85.7% sensitivity, 84.6% specificity, 85.2% accuracy, and 53.7° cutoff value for the talus-pTTL angle. AUC was 0.86 with 82.1% sensitivity, 79.5% specificity, and 80.8% accuracy for observer 1 and 0.79 with 57.1% sensitivity, 92.3% specificity, and 74.7% accuracy for observer 2 for the MCS. Different MCS values and additional capabilities when complemented with the angle measurement showed an increase in diagnostic performances. Intra-observer reliability of MCS and talus-pTTL angle of the two radiologists was excellent. Inter-observer reliability of the two radiologists was excellent for both the talus-pTTL angle (0.95) and the MCS (0.85). Measurement of the talus-pTTL angle showed good sensitivity, specificity, and accuracy for the evaluation of aTTL injury with excellent inter-observer reliability.

TU8.8 Fundoplication or gastropexy in emergency giant hiatus hernia repair?

Abstract Aims Operative management of emergency presentation with a hiatal hernia aims to reduce the herniated stomach, dissect the hernial sac and reapproximate the crura. This will often be followed by fundoplication or gastropexy to minimise the risk of recurrence. This study compares the recurrence rates between patients who underwent fundoplication and gastropexy. Methods From October 2012 to November 2020, 80 patients were admitted to a tertiary oesophagogastric centre requiring emergency surgery to repair a giant hiatal hernia. We conducted a retrospective review and analysis of their admission and follow-up. The primary outcome measure was acute and post-discharge symptomatic recurrence of hiatal hernia. Results Of the 80 patients requiring emergency hiatal hernia surgery, 38% had fundoplication procedures, 53% had gastropexy, and 3% had both (n 30, 42, 2 respectively). One patient had neither, and 6% (n 5) patients had a complete or partial stomach resection due to necrosis. Eight patients (10%) had a symptomatic recurrence of hiatal hernia requiring a repeat operation; three within the index admission, five postdischarge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n 4, 3, 1)(p-value 0.5). 19% (n 15) patients were readmitted. Post-operative mortality was 6% (n 5). Conclusions There is no conclusive evidence in the literature favouring fundoplication versus gastropexy. The surgeon's experience and patient factors influence choice of technique. This review, which includes the largest cohort of patients available in the literature, demonstrates that surgical technique does not influence the symptomatic recurrence rate in our patient group.

Advances in the research of centration in small incision lenticule extraction

Small incision lenticule extraction (SMILE) is a new technique that exhibits excellent efficacy, safety and predictability for the correction of myopia and myopic astigmatism. However, one potential limitation of this technique is that the centration during femtosecond laser cutting might be subject to the surgeon's experience and patient's cooperation. To achieve accurate centration in SMILE is the key to obtaining good postoperative visual outcomes. This review summarizes relevant research results and discusses the centration methods and the influencing factors in SMILE, so as to provide reference for clinical practice of SMILE.

Outcomes and Satisfaction after Penile Silicone Implant Surgery

ABSTRACT Introduction Penuma®, a penile silicone sleeve implant, first developed in 2004, is the first FDA-approved penile implant for cosmetic enhancement. The company endorses that on average, girth and flaccid length are increased by one to two inches. Given the novelty of the device and the scarcity of surgeons trained in placement, data regarding surgical outcomes as well as patient satisfaction are limited. It is thought that patient selection is a critical contributor to the ultimate success of the surgery. Post-operative complications have previously been described and can include seroma, infection, and explanation. Objective This study aims to characterize the outcomes of two surgeon's experience with the Penuma device and to analyze patient's perspective regarding the effects of the surgery on penile size, perceived appearance and self-esteem. Methods Retrospective chart review was performed on patients that were six months or greater from initial date of surgery. Progress notes from follow up appointments as well as telephone encounters were reviewed to look for patient complaints, post-operative physical exams, and post operative procedures. Subsequent operative reports apart from initial implant were also reviewed. An electronic survey assessing various aspects of penile satisfaction before and after the implant was sent to patients who were six months or greater from surgery and still had the device in place. Results From April 2019 to February 2021, 70 patients underwent insertion of subcutaneous soft silicone penile implant (Penuma ®) with two surgeons. 8 of these patients (11%) subsequently underwent removal of the device, reasons for which included pain, dissatisfaction with the device, and device erosion. 19 patients (27%) experienced postoperative seromas, of which 14 required drainage. Four patients (5.7%) required operative revision. A follow up survey was sent to one surgeon's patient population of 26 patients, for which we received a 100% response rate. With regards to patient satisfaction, 65.4% of patients self-reported being “dissatisfied” or “very dissatisfied” with the appearance of their penis before the implant compared to 96% who reported being “satisfied” or “very satisfied” after the implant. 84.6% of patients reported being “satisfied” or “very satisfied” with how natural their penis looks after the implant, with 3.8% reporting being “very dissatisfied.” 65.4% reported feeling “very dissatisfied” with self-confidence with regards to their penis prior to surgery, while 92.4% felt “satisfied” or “very satisfied” regarding the same after surgery. Overall, 84.6% of responders “agreed” or “somewhat agreed” that they would opt to undergo surgery again. Conclusions The Penuma® penile sleeve implant can improve patient self-satisfaction and self-confidence with regards to the appearance of their penis while maintaining a natural feel. Post operative complications, including need for re-operation, are low but not negligible. The number of surgeons that currently offer the Penuma® implant surgery in the United States is quite small, and this study suggests that it may be a successful potential option for men with penile dysmorphic disorder. Disclosure No

Traditional Anthropometrics versus Computerized Photograph Manipulation in Rhinoplasty Planning.

Rhinoplasty planning requires meticulous forethought and is a source of challenge to surgeons. Traditional anthropometric analyses aim to use measurements and ideal ratios to determine the appropriate changes in nasal measurements such as length and tip projection. More recently, computerized photograph manipulation has been adopted as a means to demonstrate to patients the planned changes in a rhinoplasty and improve communication and patient confidence. It remains undetermined if the changes recommended using traditional anthropometric rhinoplasty planning are similar to those done by an experienced rhinoplasty surgeon manipulating preoperative photographs to an aesthetic ideal. Preoperative photographs obtained for clinical use were analyzed from 97 consecutive patients seen in clinic for rhinoplasty or septorhinoplasty by the senior author (R.H.G.). Facial and nasal anthropometric measurements were performed on the preoperative photographs. The analysis prescribed by Byrd and Hobar was used to then calculate their prescribed "ideal" nasal anthropometrics. Separately, these patients had their preoperative photographs manipulated using computer manipulation software by the senior author, with an eye toward creating an aesthetically pleasing nose. Nasal anthropometrics were measured from the manipulated photographs. The changes prescribed in traditional anthropometrics were compared to those obtained from computer manipulation using univariate analyses. The mean patient age was 35.4 years, and the population was 68% female. Average nasal proportions from the computer manipulation were a nasal length 76.1% of the midfacial height, tip projection of 57.7% of nasal length, and radix projection of 24.3% of nasal length. Computerized manipulation minimally changed nasal length relative to Byrd's analysis which decreased nasal length on average (100.3% of the original nasal length versus 88.2%, p<0.01). It prescribed a greater decrease in tip projection than Byrd's analysis (97.7% of original projection versus 99.9% of original projection, p=0.05). Computer manipulation also prescribed a lesser increase in radix projection than Byrd's analysis (100.5% of original radix projection versus 109.3% of original radix projection, p<0.01). Byrd's analysis remains an excellent tool for guiding the changes in nasal dimensions in rhinoplasty. However, computerized manipulation may help patients and surgeons communicate a common goal. Their desired nasal dimensions may differ from those traditionally prescribed. Specifically, some patients may seek lesser decreases in nasal length or lesser increases in radix projection than Byrd's analysis prescribes. Further research in this topic is warranted, and ultimately the surgeon's judgment and patient goals should drive surgical planning. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .

Combined sialendoscopic/mini-preauricular microscopic approach for large proximal parotid sialolithiasis

ObjectiveTo describe and evaluate a combined approach for sialendoscopic stone localization with microscopic mini-preauricular incision external stone extraction as a gland-sparing minimally invasive surgical management in cases of large proximal duct or intraparenchymal parotid gland sialolithiasis. MethodsA retrospective chart review of a single primary surgeon's patient series of 21 cases operated in a 5-year period in a tertiary care university and private practice hospitals. ResultsStudy included 16 males and five females, with age range 12–68 years (mean 40.9 ± 14.5). Nineteen out of the 21 patients had their stones completely removed (90.5%), with two not completing the procedure due to inability of intraoperative endoscopic stone visualization. In total 25 stones were extracted with six patients having two stones. Longest diameter of single (or first) stone was 5–16 mm (mean 9.1 ± 2.9) and second was 3–5 mm (mean, 3.9 ± 0.6). Endoscopic findings showed 14/25 stones in the proximal main parotid duct and 11/25 in one of its secondary parenchymal branches. Stents were used in 4/19 cases (21.1%). No major complications occurred. Minor complications included two postoperative conservatively managed seromas. All 19 cases had completely intact facial nerve function, good parotid salivary flow and acceptable esthetic result after median follow-up period of 26 months (range 6–62). ConclusionThe combined sialendoscopic/microscopic mini-preauricular approach is a highly effective and safe gland-preserving method for large proximal parotid sialolithiasis management with a main limitation being inability to visualize the stone endoscopically.

Water Dynamics in Unilateral Biportal Endoscopic Spine Surgery and Its Related Factors: An In Vivo Proportional Regression and Proficiency-Matched Study

Stable water dynamics during endoscopic spine surgery improves the surgeon's comfort and patient's outcomes. We aimed to measure the water dynamics during spinal surgery and identify the factors that facilitate stable water dynamics. This open-label, prospective, proficiency-matched, invivo study included patients with single-level degenerative spinal disease. After assessing their heights and balancing the matched instrument, we measured the irrigation fluid pressure in various situations. We performed multiple regression analysis based on odds ratio(OR), confidence interval (CI), and relationships (proficiency-matched) with possible instrumental and physical characteristics. The instrumental factors were the presence and length of a rigid cannulation, and the physical characteristics were body mass index (body mass index [BMI]), skin-to-dura depth, height (interaction with BMI), and body weight (interaction with BMI). Of the 36 patients, 29 were included. The mean pressure of the operation cavity was 16.66 ± 9.12 cm H2O (12.25 ± 6.71 mm Hg). Water pressure with the rigid cannulation (9.41 ± 2.94 cm H2O [6.92 ± 2.16 mm Hg]) was significantly lower than that without cannulation (23.43 ± 7.57 cm H2O [17.26 ± 5.57 mm Hg], P < 0.01). Water pressure correlated with cannular length (OR=-1.08, CI=-1.79,-0.37, P < 0.01) and BMI (OR= 0.56, CI= 0.12, 0.99, P < 0.01). BMI showed a proportional relationship (r=0.84, P < 0.01). During biportal endoscopy, we suggest maintaining water pressure between 4.41 cm H2O (2.41 mm Hg) and 31.00 cm H2O (22.83 mm Hg). Compared to physical characteristics, placement of the cannula and appropriate cannula length are important factors that affect water dynamics.

Surgical treatment of bulbar urethral strictures: tips and tricks.

ABSTRACTThe surgical treatment of bulbar urethral strictures is still one of the most challenging reconstructive-surgery problems. Bulbar urethral strictures are usually categorized as traumatic and non-traumatic strictures depending on the aetiology. The traumatic strictures are caused by trauma and they determine disruption of the urethra with obliteration of the urethral lumen, ending with fibrotic gaps between the urethral ends. Differently, the non-traumatic urethral strictures are mainly caused by catheterization, instrumentation, and infection, or they can also be idiopathic. They are usually associated with spongiofibrosis of the segment of the urethra that has been involved. Worldwide, two different surgical approaches are currently adopted for bulbar urethral repair: transecting techniques with end-to-end anastomosis and non-transecting techniques followed by grafting. Traumatic obliterated strictures require transection of the urethra allowing complete removal of the fibrotic tissue that involves the urethral ends. Conversely, non-traumatic, non-obliterated urethral strictures require augmentation of the urethral plate using oral mucosa grafts. Nowadays, it is still difficult to choose the correct surgical management for non-obliterated bulbar stricture repair. Indeed, different surgical techniques have been proposed (pedicled flap vs free graft, dorsal vs ventral placement of the graft, non-transecting technique using or non-using free graft, etc.) but none emerged as the best solution since all techniques have showed similar success and complication rates. Consequently, the final choice is still based on surgeon’s preferences and patient’s characteristics. Within the current manuscript, we like to present some of our tips and tricks that we developed along our prolonged surgical experience on the treatment of bulbar urethral strictures. These might be of interest for surgeons that approach this complex surgery. Moreover, our suggestions want to be useful regardless the type of chosen technique being adaptable for different scenario.

Incidence of Obstetric Lacerations and Episiotomy Following Labiaplasty.

A significant proportion of patients seeking labiaplasty are nulliparous and may experience later changes to their labia following vaginal delivery. In the present study, the authors reported the long-term outcomes of a single surgeon's patient cohort who had vaginal delivery after labiaplasty. A retrospective chart review of the senior author's database was conducted. All patients who underwent in-office labiaplasty from 2007 to 2018 were surveyed. The resulting cohort was stratified into patients who had delivered children prior to labiaplasty and those who delivered after labiaplasty. A total of 204 patients responded to a phone survey. Seventy patients had children prior to undergoing labiaplasty, and 33 had children after labiaplasty. The rate of vaginal delivery was lower in the women who had children before labiaplasty (82.6% vs 91.8%, P = 0.015). The tear/episiotomy rate for vaginal deliveries was lower in women who had children prior to labiaplasty compared with after labiaplasty (3.1% vs 17.8%, P < 0.001). Among the women who had children only after labiaplasty, the reported tear/episiotomy rate was 7/39 vaginal deliveries (17.9%). Patients in our cohort had over 90% success with vaginal deliveries after labiaplasty. For nulliparous patients contemplating the procedure, the data we present suggest the risk of episiotomy or vaginal tear risk with vaginal birth after labiaplasty is comparable with or lower than the general population, further supporting the safety of this procedure. For patients with previous delivery, the data are more limited but suggest no increased risk in this small cohort.