Reimplantation Technique Research Articles

Bilateral ureteral ectopia with duplex collecting system and hypoplastic bladder: a rare variant

BackgroundBilateral single system ectopic ureter is a rare congenital anomaly, but bilateral ureteral ectopia with duplex collecting system with bladder hypoplasia is even rarer. Urinary incontinence in such cases is dealt with various reconstructive procedures.Case presentationA 20-year-old female presented with continuous urinary incontinence without normal voiding since birth. Imaging revealed bilateral duplex collecting system with ectopic ureter draining into the vestibule, and hypoplastic bladder. The patient was managed with Mainz-II pouch creation with serous lined extramural ureteral reimplantation technique with complete resolution of incontinence.ConclusionOur article highlights the challenges in surgical planning, treatment and the patient perspectives for this rare congenital malformation presenting with incontinence.

Reimplantation versus aortic ring annuloplasty in bicuspid valve with borderline aortic root ectasia.

ObjectiveBicuspid aortic valve repair can be achieved with the reimplantation technique or external ring annuloplasty. Reimplantation could be an “overtreatment” in nonaneurysmatic aortic roots. External ring repair, on the contrary, could be an “undertreatment” in dilated roots. The aim of this retrospective study is to compare the 2 techniques in patients with borderline aortic root dimensions, analyzing early results, aortic regurgitation recurrence, and root dilation over time.MethodsWe selected patients with bicuspid aortic valve and ectasia of the aortic root (40-48 mm) who underwent reimplantation or external ring repair. We compared the 2 techniques, analyzing immediate postoperative and follow-up echocardiography. Only patients with at least 1 year of follow-up were included.ResultsWe obtained 2 groups of 21 patients (reimplantation) and 22 patients (external ring). Median follow-up time was 36 (40) months. There were no deaths during the follow-up periods. Three patients required reoperation in the external ring group because of recurrent aortic regurgitation, with a freedom from reoperation of 77.8% at 7 years (no reoperation was required in the reimplantation group). In the external ring group, we observed an immediate postoperative root diameter reduction and no significative expansion during follow-up (+0.4 mm/year, P = .184).ConclusionsExcellent results of reimplantation technique are confirmed and stable over time. Root diameter seems to remain stable over time when external ring technique was performed. The greater incidence of reoperation after external ring could be due to the progressive learning curve (256 patients vs 52 patients). Longer follow-up studies are needed.

Very asymmetrical bicuspid aortic valve repair with the reimplantation technique: From type C to type B.

Bicuspid aortic valves (BAVs) have been recently divided into 3 different types in a repair-oriented classification1: type A or symmetrical valves, type B or asymmetrical valves, and type C or very asymmetrical valves. Very asymmetrical BAVs are nearly tricuspid valves with a very short fusion and a developed nonfunctional commissure. This is the reason why they are usually best treated as a tricuspid valve. However, the repair of a type C valve is a surgical challenge and the debate on which is the most appropriate technique is still open.

Research Status and Future Development of Cochlear Reimplantation.

Cochlear implants are the most successful sensory prostheses worldwide, and they can be useful for patients with severe and profound hearing impairment. However, various complications, including infection, pain, and device failure which is mainly due to falls and trauma, are associated with the use of cochlear implants. Reimplantation is required to replace the initial device in severe complications. Nevertheless, reimplantation can present certain surgical risks and may impose a significant economic and psychological burden on patients and their families; therefore, it requires greater attention and focus. This article presents a review of the literature on cochlear reimplantation and summarizes the current status, knowledge gaps, and future research directions on cochlear reimplantation. Since 1980s, cochlear reimplantation techniques can be considered to be relatively mature; however, some clinical and scientific problems remain unresolved, including the lack of a unified definition of cochlear reimplantation, non-standardized calculation of the reimplantation rat, and insufficient effect assessment. This review highlights the urgent need to establish an international consensus statement on cochlear reimplantation research to standardize the definition, calculation formulas of reimplantation rate, and follow-up systems.

Modified Cabrol technique for the treatment of adult anomalous left coronary artery from the pulmonary artery

BackgroundAnomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly that typically presents within the first year of life but can also sporadically present in adults. ALCAPA, if left untreated, can lead to coronary ischemia and sudden death.Case presentationWe present the case of a 32-year-old male with ALCAPA with ischemic cardiomyopathy and the anomalous left main coronary originating from the non-facing sinus of the pulmonary artery (PA). A posterior reimplantation of the anomalous coronary artery was accomplished with a modified Cabrol technique using synthetic polytetrafluoroethylene (PTFE) graft.ConclusionsA posterior re-implantation technique using a modified Cabrol graft, in cases where length of the native button is challenging, has excellent outcomes for this rather rare and challenging clinical entity.

Long-term durability of a reimplantationvalve-sparing aortic root replacement can be expected in both Marfan syndrome and Loeys-Dietz syndrome.

The goal of this study was to evaluate the surgical outcomes of a valve-sparing root replacement using the reimplantation technique for annuloaortic ectasia in patients with Marfan syndrome (MFS) and in those with Loeys-Dietz syndrome (LDS). We reviewed 103 patients with MSF with mutations in the fibrillin-1 gene and 28 patients with LDS with mutations in the transforming growth factor-beta receptor and 2, SMAD3 and transforming growth factor beta-2 from 1988 to 2020. Forty-four (42.7%) patients with MFS [26 men, 31 (7.6) years] and 10 (35.7%) patients with Loeys-Dietz syndrome (LDS) [7 men, 22 (standard deviation: 8.6) years] who had no aortic dissection and underwent valve-sparing root replacement were included. The preoperative sinus diameter [46 (45-50.5) mm in those with MFS vs 48 (47-50) mm in those with LDS, p = 0.420] and the percentage of aortic insufficiency > grade 2+ [31.8% (10/44) in patients with MFS vs 10.0% (1/10) in those with LDS, p = 0.667] revealed no significant differences between the 2 groups. The cumulative incidences of aortic insufficiency greater than grade 1 (p = 0.588) and aortic valve reoperation (p = 0.310) were comparable between the 2 groups. Patients with LDS had a higher tendency towards aortic dissection after the initial operation (p = 0.061) and a significantly higher cumulative incidence of aortic reoperation (p = 0.003) versus those with MFS. Patients with MFS and those with LDS showed similar cumulative incidences of recurrent aortic valve insufficiency and aortic valve reoperation. Those with LDS revealed a higher cumulative incidence of aortic reoperation and a greater tendency towards aortic dissection after the initial operation compared with those with MFS.

V81 - A novel modification for ureteral reimplantation technique (Combined technique) in pediatric patients: A preliminary case series

V81 - A novel modification for ureteral reimplantation technique (Combined technique) in pediatric patients: A preliminary case series

УСОВЕРШЕНСТВОВАНИЕ МЕТОДА ЭКСТРАВЕЗИКАЛЬНОЙ РЕИМПЛАНТАЦИИ МОЧЕТОЧНИКА

Objective: To optimize the technique of extravesical ureteral reimplantation in experimental animals. Methods: Experiments were carried out on 21 Flanders rabbits. Initially, ureterohydronephrosis (UHN) was modeled by alcoholization of the ureter in its vesical part according to the method of Ya.V. Gudynsky. After 21 days, the animals underwent extravesical ureteral reimplantation using the technique optimized by the team of urologists. Results: The stents were removed endoscopically on the 20th day. In order to exclude vesicoureteral reflux, contrast cystography was performed, in which reflux was not detected. To exclude obstruction, on the 30th, 60th, and 90th days after the operation, an ultrasound scanning of the urinary system was performed, in which the presence of UHN was not noted. On the 90th day, the experimental animals underwent resection of the anastomotic zone for histological examination. It was found that the diameter of the transplanted segment corresponded to the normal size of the rabbit ureter, there was a slight thickening of the ureteric wall, its hypertrophy, and intracellular hyperplasia. Conclusion: The effectiveness and safety of the proposed method of extravesical ureteral reimplantation with antireflux protection has been experimentally proven. Keywords: Ureter, urodynamics, obstruction, ureterohydronephrosis, megaureter.

Ross procedure with pulmonary autograft reinforcement using reimplantation technique

Dilatation of the pulmonary autograft resulting in aortic valve regurgitation represents a common issue following Ross procedure with root replacement, in particular when performed beyond childhood. We present our early experience with modified Ross procedure associated with autograft reinforcement using reimplantation technique. Records of 59 consecutive patients who underwent Ross procedure with reinforcement between 2009 and 2021were analysed. Pulmonary autograft was reimplanted in a Dacron conduit of a median diameter = 26 mm (range: 20–30) using Tirone David's technique of valve sparing aortic root replacement (VSRR). Median age was 17 years (range: 6–38). Majority of cases has presented with mono or bicuspid aortic valve ( n = 50; 85%), predominant aortic valve regurgitation ( n = 38; 64%) and dilatation (> 30 mm) of the ascending aorta ( n = 32; 54%). Forty-six (78%) had at least one prior aortic valve procedure. No death occurred. Three patients required early procedure-related reoperation 8 others were reoperated on later resulting in 3 neo-aortic valve replacement all-over (5%). The mean duration of follow-up was 46 ± 12 months. Neither more than mild autograft regurgitation nor stenosis was observed. Mean diameters of the autograft annulus and sinotubular junction were respectively 24.8 ± 2.6 mm and 25.3 ± 2.1 mm at discharge and 25.3 ± 2.1 mm and 25.4 ± 2.7 mm at the last visit ( P = 0.06 and 0.08). Autograft reinforcement by means of reimplantation technique prevented neo-aortic root dilatation and allowed to extend the indications for Ross procedure to patients for whom the conventional Ross technique was qualified to be unsuitable. Early failure was rare (5%) and mid-term outcomes confirmed the stability of the neo-aortic valve function in follow-up.

Direct Reimplantation Procedure in Anomalous Aortic Origin of the Right Coronary Artery: Long-Term Single Center Outcomes.

Anomalous aortic origin of the right coronary artery is known to be a cause of sudden cardiac death in athletes. There are no specific guidelines concerning treatment strategy in the literature. The aim of this study is to describe and report our experience of direct reimplantation technique in the treatment of this anomaly. This was a retrospective single center study of 30 patients who underwent surgery in the congenital heart disease unit of Louis Pradel Heart and Lung Hospital between January 2003 and December 2016. The mean follow-up was seven years (3 months-17 years). Thirty patients underwent surgery. The median age was 17 years (0.2-52 years). There were 24 males. The median weight was 58 kg (3.6-118 kg). Fourteen patients were actively engaged in sports. Twenty-six patients had exertional chest pain or syncope. The median time lapse between diagnosis and intervention was 4.5 months (0.5-179 months). Twenty-seven (90%) patients underwent reimplantation of the anomalous coronary artery without transverse aortotomy, while in 3 (10%) patients transverse aortotomy was used to facilitate reimplantation to avoid tension at the anastomosis. There was no early death; one late death occurred in the third postoperative month. At the last follow-up, all patients had returned to normal physical activity without evidence of ischemia. Direct reimplantation allows for a complete restoration of the coronary anatomy and enables patients to return to normal physical activity. Our study shows encouraging results using a direct reimplantation technique without aortotomy.

Robotic Ureteral Reimplantation: Nonrefluxing Intravesical and Extravesical Techniques

Introduction: Nonrefluxing ureteral reimplantation is the gold standard surgical management of patients with symptomatic vesicoureteral reflux (VUR).1,2 Intravesical and extravesical ureteral reimplantation were traditionally performed with an open approach through the Cohen, Lich-Gregoir, Glen-Anderson, and Politano-Leadbetter techniques.3 However, there has been recent adoption of minimally invasive approaches including the use of robotic assistance.1 Moreover, these nonrefluxing ureteral reimplantation techniques have been primarily described in the pediatric population rather than in adults.2 We demonstrate our techniques and describe outcomes of adult patients undergoing nonrefluxing intravesical and extravesical robotic ureteral reimplantation (RUR). Materials and Methods: We reviewed our institution's own robotic ureteral reconstruction database to identify consecutive adult patients with a history of VUR who underwent nonrefluxing intravesical or extravesical RUR between September 2016 and November 2020. Indications for surgery included patients with symptoms of flank pain and/or recurrent infections secondary to VUR. Our primary outcome was surgical success, which we defined as the absence of postoperative flank pain and radiographic absence of VUR on voiding cystourethrogram or obstruction on diuretic renal scan. Before beginning the procedure, all patients underwent cystoscopy, cystogram, and/or retrograde pyelogram. Robotic ports are placed similarly for both techniques through the standard prostatectomy configuration without a fourth robotic port or the right lateral 12 mm assistant port. A 5 or 12 mm assistant port is placed between the camera and the right robotic port. Meticulous dissection of the distal ureter to preserve its fragile blood supply is performed for both techniques. In the robotic intravesical technique, adapted from the Politano-Leadbetter technique, the ureter is redirected through a new supratrigonal hiatus and submucosal tunnel created in a 5:1 ratio.4 The neoureteral orifice (UO) is relocated distally (subtrigonometry) and medial to the orthotopic UO. In the robotic extravesical technique, adapted from the Lich-Gregoir technique, a mucosa sparing extravesical tunnel is created according to the Paquin guidelines with a 5:1 length to diameter ratio.5,6 In patients who have a previous ureteroneocystostomy complicated by reflux symptoms, the existing reimplant site can be left intact and revised with an extravesical tunnel to prevent reflux. Results: Three patients met inclusion criteria. Two patients underwent nonrefluxing extravesical RUR and one patient underwent intravesical RUR. The patient who underwent an extravesical RUR had a history of reimplantation that was complicated by severe reflux-related symptoms. Intraoperatively, the mean estimated blood loss was 50 mL and mean robotic console time was 162 minutes. Postoperatively, none of the patients experienced major (Clavien >2) complications. With regard to surgical success, at a mean follow-up of 20.5 months, all patients were free of urinary tract infections and obstructive flank pain symptoms. In addition, all patients achieved complete resolution of VUR on postoperative voiding cystourethrogram or renal scan. Conclusions: Nonrefluxing intravesical and extravesical RUR may be safely and effectively utilized for surgical management of adult patients with symptomatic VUR. Moreover, the nonrefluxing extravesical RUR can be used to revise select patients with prior reimplantation complicated by symptomatic reflux. S.K., C.O., and M.L. have no competing financial interests. D.D.E. reports a relationship with Intuitive Surgical that includes consulting or advisory and speaking and lecture fees. D.D.E. reports a relationship with Melzi Corp that includes board membership. D.D.E. reports a relationship with Johnson and Johnson that includes consulting or advisory. Accepted for presentation at Mid-Atlantic AUA 2021. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: Music (Gentle Wave by Ketsa) is not copyrighted material and was obtained from a royalty-free source. Runtime of video: 7 mins 14 secs

Laparoscopic ureteral reimplantation applying the modified psoas hitch and Lich-Gregoir onlay technique: a 10-step surgical video.

Describe the surgical technique of laparoscopic ureterovesical reimplantation applying the modified psoas hitch with Lich-Gregoire onlay technique to manage a distal ureteral fistula after a hysterectomy for a gynecologic malignancy. This video illustrates the surgical technique of laparoscopic ureteral reimplantation applying the modified psoas hitch with Lich-Gregoire onlay technique in a ten-step surgical video. Step 1: closure of the caudal ureter.Step 2: Ureter mobilization. Step 3: Ureter spatulation. Step 4: Bladder mobilization. Step 5: Detrusor muscle incision. Step 6: Bladder suspension. Step 7: Mucosal incision. Step 8: Ureterovesical anastomosis. Step 9: JJ stent insertion. Step 10: Detrusor muscle closure. Intraoperative identification of ureteral injury and prompt repair are recommended. Ureteral repair technique depends on the ureteral injury site. Distal ureteral injuries (UIs) might require either uretero-ureterostomy or ureteral reimplant with or without a psoas hitch. The Lich-Gregoir is one of the two most frequently used anti-vesicoureteral reflux techniques and has acceptable complication rates.

Valve sparing root replacement with the reimplantation technique in patients presenting with acute type A aortic dissections

: Patients presenting with acute type A aortic dissections (ATAAD) comprise an extremely heterogenous population. While a majority are older and suffer from chronic disease states, a non-insignificant minority are relatively healthy without long standing aneurysmal or aortic valve pathology. Selection of an appropriate proximal and distal operation can affect short- and long-term morbidity and mortality as well as the need for valve reintervention. In regard to management of the root, surgeons must be aggressive when indications for replacement—such as a sinus tear, aneurysmal degeneration, or friable tissue—are evident. In experienced centers, it is reasonable to proceed with a valve-sparing procedure in well selected patients. The risks and benefits of this decision must be considered carefully as a root replacement with either a biologic or mechanical prosthesis is preferred over a poorly executed valve sparing procedure. However, if the latter is approached in a standardized fashion with attention to the patient’s overall acuity, cardiac function, and aortic valve leaflet mobility, reproducible outcomes can and should be expected. Accordingly, we present our approach to valve sparing root replacement with the reimplantation technique in ATAAD. The following review includes a case-based discussion and video depiction of our technique, including safe and reliable cannulation methods for bypass, cerebral protection strategies, and a structured approach to critically appraise the valve prior to repair.

Early outcome of valve sparing aortic root replacement with partial upper sternotomy

Objective: To examine the early outcome of valve sparing aortic root replacement with reimplantation technique (David procedure) with partial upper sternotomy. Methods: From April 2016 to April 2020, 31 patients underwent valve sparing aortic root replacement under partial upper sternotomy at Vascular Surgery Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. There were 28 males and 3 females, aging (44±13) years (range: 11 to 65 years). Preoperative aortic regurgitation was found greater than moderate in 15 patients, moderate in 6 patients and less than moderate in 10 patients. The diameter of aortic annulus was (26±3) mm (range: 21 to 34 mm), the diameter of aortic sinus was (51±6) mm (range: 41 to 68 mm), the diameter of ascending aorta was (43±8) mm (range: 26 to 62 mm). The preoperative ejection fraction was (65±4) % (range: 59% to 72%) and left ventricular end-diastolic diameter was (55±6) mm (range: 42 to 68 mm). All cases were treated with David Ⅰ procedure, including simple David procedure in 26 patients, David+ascending aorta and partial aortic arch replacement in 3 patients, David+thoracic endovascular aortic repair in 1 patient, David+stent elephant trunk implantation in 1 patient. Results: The operation time, cardiopulmonary bypass time and aortic cross-clamping time were (330±58) minutes (range: 214 to 481 minutes), (138±23) minutes (range: 106 to 192 minutes) and (108±17) minutes (range: 82 to 154 minutes), respectively. There were no death and serious complications (stroke, myocardial infarction, renal insufficiency, severe infection, etc.). The postoperative drainage volume within 24 hours was (314±145) ml (range: 130 to 830 ml). The intubation time was (14±3) hours (range: 8 to 21 hours), and the ICU time was (M(QR)) 2.1(1.5) days (range: 1.0 to 5.0 days). Eight patients had no blood transfusion, the proportion of red blood cell use was 9.7% (3/31), plasma use was 22.6% (7/31), and platelet use was 71.0% (22/31). The postoperative left ventricular ejection fraction was (62±4)% (range: 54% to 69%), and left ventricular end-diastolic diameter was (48±4) mm (range: 39 to 56 mm). After operation, aortic regurgitation was significantly improved, with no more than moderate regurgitation, small to moderate regurgitation in 3 patients, minor regurgitation in 3 patients, micro regurgitation in 12 patients and no regurgitation in 13 patients. The follow-up period was 3.5(6.1) months (range: 2.0 to 39.0 months). Echocardiographic follow-up data were obtained in 26 cases, including moderate regurgitation in 1 patient, small to moderate regurgitation in 9 patients, minor regurgitation in 5 patients, micro regurgitation in 6 patients and no regurgitation in 5 patients. There were no major adverse cardiovascular events and aortic events during the follow-up period. No patient was reoperated for aortic regurgitation. Conclusion: Valve sparing aortic root replacement under partial upper sternotomy is safe and feasible, and the early result is satisfactory.

Extravesical Common Sheath Ureteral Reimplantation Versus Intravesical Techniques for Refluxing Duplex Systems in Children.

Retrospective comparative study of the efficacy of extravesical non-dismembered common sheath ureteral reimplantation (ECSR) versus intravesical common sheath ureteral reimplantation (ICSR) techniques for the correction of vesicoureteral reflux (VUR) in complete duplex systems. Between 2010 and 2019, ECSR was performed in 38 children (8 bilaterally), and the mean ages at presentation and at surgery were 31 and 57 months, respectively. The ICSR technique was performed in 25 units (25 patients). Voiding cystography and ultrasound of the kidney and bladder were performed 3 and 12 months postoperatively. We analyzed the surgical outcomes for both groups. The mean follow-up times for the ECSR and ICSR groups were 15 and 18 months, respectively. The success rate of the ECSR group was 93.5% at 3 months, improving to 95.7% at an average of one year; the rate of the ICSR group was 96% at 3 months and was the same after one year, with no significant difference between the two groups (p = .66). Postoperative complications were compared in the ECSR and ICSR groups: transient contralateral VUR was seen in 5 renal units versus 4, de novo hydronephrosis was seen in 3 units versus 2, and UTIs were observed in 3 patients versus 4. Both (ECSR) and (ICSR) surgeries are highly successful for the correction of VUR in uncomplicated complete duplex systems. The results of the extravesical approach are comparable with those of the intravesical technique with less morbidity and a shorter hospital stay. Thus, ECSR is our preferred technique when open surgical repair is indicated. ICSR should be reserved for complicated duplex systems necessitating concomitant reconstructive surgery.

Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel

IntroductionUreteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. Material and methodsDescriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05. ResultsThe study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). ConclusionSurgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Neo-aortic posterior sinus of Valsalva reduction and closed coronary artery transfer as a method to approach aortopulmonary mismatch in transposition of great arteries.

In transposition of great arteries (TGA), aortopulmonary mismatch (APM) can determine postoperative neo-aortic insufficiency after arterial switch operation (ASO). The distortion of sinu-tubular junction may be the geometric mechanism responsible. We developed a strategy able to reduce the mismatch at the timing of ASO, and in this study, we aimed to describe our indications and results. Preoperative root circumferences at the level of the mid-portion of sinus of Valsalva and ascending aorta circumference were used to define APM. Indication to surgery was a neo-aortic root (NAR) to ascending aorta ratio ≥ 1.4. Along with standard ASO, posterior neo-aortic sinus inverted conal resection and punch technique for coronary reimplantation was used in all patients to re-establish the more geometric ratio possible between the two components. Hypoplastic aortic arch (HAA) and aortic coarctation (CA) were managed by aortic arch enlargement with an autologous pericardial patch. Twenty patients (20 male), 19 with diagnoses TGA (17 with ventricular septal defect, 85%) and 1 with Taussig-Bing anomaly underwent ASO. HAA was present in three (15%) and CA in two (10%). The mean preoperative neo-aortic to ascending aorta ratio was 1.8 versus 1.1 postoperatively (p < .01). No moderate or severe neo-aortic insufficiency was observed before discharge and at a mean follow-up of 4.3 years (interquartile range = 0.5-12 years). Neo-aortic reduction plasty with coronary reimplantation by punch technique is an effective strategy to approach preoperative APM in TGA. This technique confers a more harmonious geometry to NAR that can improve neo-aortic valve function.

31 Pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy: A video case presentation

This presentation discusses a rare case of pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy. The patient is an 81-year-old who presented to the office with continuous leakage of urine. She had a history of pelvic organ prolapse that was treated with a Gellhorn pessary for the past 5 years, however, she was lost to follow-up 2 years ago. On physical examination and cystoscopy, the patient’s pessary was found to be eroded into the bladder near the trigone. Office removal of the pessary was not possible. The patient initially underwent pessary removal under anesthesia with repair of her vesicovaginal fistula. On cystoscopy prior to and after the procedure, no efflux of urine was seen from the left ureter. A CT urogram performed on post-operative day 1 demonstrated hydronephrosis with obstruction of the left ureter, so a left nephrostomy tube was placed. A second CT urogram several weeks later demonstrated recurrence of the vesicovaginal fistula. One month following the initial procedure, she underwent a robotic-assisted ureteroneocystostomy with psoas hitch and vesicovaginal fistula re-closure. A postoperative CT urogram demonstrated patency of both ureters without leakage. Three weeks post-operatively she had only minor complaints, and denied leakage of urine from the vagina. A plan was made to repeat the CT urogram in 3 weeks and hopefully remove the left ureteral stent placed during her second surgery. This video enforces the importance of regular pessary follow-up, and highlights a rare but serious complication that could develop. It also showcases careful technique for robotic-assisted ureteral re-implantation.

Incidence of spinal cord ischemia according to the patency of reimplanted segmental arteries during thoracoabdominal aortic replacement.

This study aimed to investigate the impact of segmental artery reimplantation and its patency on spinal cord ischemia (SCI) in thoracoabdominal aorta replacement. For 193 patients who underwent early postoperative computed tomographic (CT) angiography after thoracoabdominal aorta replacement, the technique of segmental artery reimplantation, their patency, and postoperative SCI were retrospectively investigated. The early patency rate of reimplanted segmental artery was 83.3% (210 of 252), as 13 were taken down intraoperatively and 42 were not visualized in the postoperative CT angiography. The patency rate differed according to the reimplantation technique: 93.6% (131/140) for en bloc patch, 95.6% (43/45) for small individual patch, and 53.7% (36/67) for graft interposition. SCI occurred in 13 (6.3%) patients, 4 of whom (2.0%) remained paraplegic permanently. SCI was significantly more frequent (P=0.044) in the patients in whom segmental artery reimplantation was not successful (take-down or occlusion, 6/37=16.2%) than in those who had all segmental arteries sacrificed intentionally (2/64=3.1%) and those who showed patency of all reimplanted segmental arteries (5/92=5.4%). Especially, there was no permanent paraplegia in the last group. Failure of intended segmental artery reimplantation was a significant risk factor of postoperative SCI in logistic regression analysis (P=0.012; odds ratio 4.65, 95% confidence interval 1.41-15.36). During thoracoabdominal aorta replacement, attention should be paid to the segmental artery reimplantation technique, which affects the risk of occlusion or intraoperative take-down and thereby may have impact on postoperative SCI.

Late results of aortic valve repair for isolated severe aortic regurgitation.

The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6±16years, and 80% were male. Median follow-up was 6.4years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14years, overall survival was 81%±5% and 71%±6%, respectively, and freedom from reoperation was 80%±5% and 73%±6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73%±5% and 66%±7% at 10 and 12years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.