Upper Pole Research Articles

The Influence of Anthropometric Factors on Renal mpMRI: Insights From Regional Analysis.

Multiparametric MRI (mpMRI) provides detailed insights into renal function, but the impact of anthropometric factors on renal imaging is not fully understood. To investigate regional correlations between mpMRI parameters and age, body mass index (BMI), and body surface area (BSA). Prospective, cross-sectional observational study. Twenty-nine healthy volunteers (44.5 ± 18.3 years, 18 females) without a history of renal disease. 3-T, pseudo-continuous arterial spin labeling, multi-echo gradient-recalled echo, diffusion-weighted imaging, T1 and T2 mapping. Bilateral kidneys were segmented into nine concentric layers (outer cortex to inner regions) and nine equiangular sections (lower to upper pole). Key parameters (renal blood flow [RBF], , apparent diffusion coefficient [ADC], T1 and T2 maps) were correlated with age, BMI, and BSA. Differences in parameters between age and BMI groups were also evaluated. Spearman correlation, Mann-Whitney U test, and rank-biserial correlation coefficient for effect size. A P-value <0.05 was considered statistically significant. RBF correlated negatively with age in all regions and BMI in inner layers and lower pole. ADC negatively correlated with BMI (significance was not reached in layers 2, 7, 8; P-value = 0.06-0.12) and BSA in layers 1-7. T1 negatively correlated with age in inner regions and lower medial pole. Significant positive correlations were found between age and (outermost layer, upper pole), age and T2 (inner and cranial-caudal regions), as well as BMI and T2 (except upper pole; P-value = 0.06). Significant differences between age groups were observed for RBF (all regions), (outermost and second innermost layers, central lateral region), T1 (innermost layer), and T2 (upper medial pole). Between BMI groups, ADC (middle layers, upper medial pole) and T2 (outermost and inner layers, lower pole to lateral region) differed significantly. Intrarenal variance of mpMRI parameters correlated with age, BMI, and BSA. 4 TECHNICAL EFFICACY: Stage 1.

8042 A Rare Case of Papillary Thyroid Carcinoma in a Patient with Li-Fraumeni Syndrome

Abstract Disclosure: K.M. Bakhtawar: None. G. Jaiswal: None. Li-Fraumeni syndrome (LFS) is an autosomal dominant syndrome with a high lifetime probability of cancer at an early age. The spectrum of cancers primarily includes osteosarcoma, soft tissue sarcoma, breast cancer, brain tumors, leukemia, and Adenoid cystic carcinoma. Prior studies have estimated the cumulative cancer risk to be about 50% by age 40 and as high as 90% by age 60. As screening for TP53 mutations has improved and more patients are identified, the LFS cancer spectrum has expanded to include thyroid cancer. However, the occurrence of thyroid cancer in LFS has not been extensively assessed in the literature. A recent study examined cancer patients carrying the Brazilian p.R337H TP53 mutation which demonstrated that out of 101 patients, 11 had thyroid cancer (10.9%). In our case, a 45-year-old female with a past medical history of Li-Fraumeni syndrome, Von Willebrand disease, Pulmonary embolism, HER-2 positive invasive ductal carcinoma of the left breast status post chemotherapy, and bilateral mastectomy presented for evaluation of papillary thyroid carcinoma (PTC). An enlarged thyroid was initially identified on physical exam by the PCP with a follow-up thyroid ultrasound showing bilateral nodules. The right upper pole 1.9 x 1.3 x 1.6 cm nodule was biopsied revealing PCT. Following neck ultrasound demonstrated mildly enlarged lymph nodes on the right side, level 2A 1.5 cm and level 3 1.6 cm. The patient subsequently underwent total thyroidectomy and lymph node dissection. The pathology report revealed a 1.4 cm PTC in the upper right pole, a 0.9 cm PCT in the isthmus, and a 0.8 cm PTC in the left midpole. 4/62 lymph nodes were positive with the largest deposit of 1 cm. All margins were negative for carcinoma with no angioinvasion or lymphatic invasion. She was staged as T1bN1bM0. We are awaiting post-operative Thyroglobulin level to assess the need for Radioactive iodine. BRAFV600E and P53 mutation was identified. The patient carries known heterozygous mutation p.R1755H in the TP53 gene with an estimated lifetime cancer risk of 93%. This particular mutation has not been associated with thyroid cancer in prior studies. Although thyroid cancer is an uncommon manifestation of LFS, this case begs the importance of further studies to explore this association which may then lead to early screening and treatment of thyroid cancer in individuals with founder TP53 mutations. Presentation: 6/1/2024

Single-center external validation and reconstruction of multiple predictive models for skip lateral lymph node metastasis in papillary thyroid carcinoma.

The unique metastatic pattern of skip lateral lymph node metastasis (SLLNM) in PTC patients may lead to missed diagnosis of lateral cervical metastatic lymph nodes. Therefore, many different SLLNM prediction models were constructed. In this study, partially eligible models (Hu 2020, Wang 2020, and Zhao 2023 nomograms) were selected for external validation, and then new variables were incorporated for model reconstruction to extend clinical applicability. 576 PTC patients from our center were selected to evaluate the performance of the three nomograms using the receiver operating characteristic curve (ROC), calibration curves, and decision curve analyses (DCA). Three new variables were added to calibrate the model, including assessment of LN status on ultrasound (US-SLLNM), the distance from the tumor to the capsule (Capsular distance), and the number of central lymph node dissections (CLND number). Univariate and multivariate logistic regression analyses were used to screen independent predictors to reconstruct the model, and 1000 Bootstrap internal validations were performed. SLLNM were present in 69/576 patients (12.0%). In external validation, the area under the ROC curves (AUCs) for Hu 2020, Wang 2020, and Zhao 2023 nomograms were 0.695 (95% CI:0.633-0.766), 0.792 (95% CI=0.73-0.845), and 0.769 (95% CI:0.713-0.824), respectively. The calibration curves for the three models were overall poorly fitted; DCA showed some net clinical benefit. Model differentiation and net clinical benefit improved by adding three new variables. Based on multivariate analysis, female, age, and maximum tumor diameter ≤ 10 mm, located at the upper pole, Capsular distance < 0mm, US-SLLNM, CLND number ≤ 5 were identified as independent predictors of SLLNM and were used to construct the new model. After 1000 Bootstrap internal validations, the mean AUC of the model was 0.870 (95% CI:0.839-0.901), the calibration curve was close to the ideal curve, and the net clinical benefit was significant. Overall, these nomograms were well differentiated and provided some net clinical benefit, but with varying degrees of underestimation or overestimation of the actual risk and high false-negative rates. New dynamic nomogram was constructed based on the addition of new variables and larger samples, showing better performance.

Robot-assisted treatment of simple renal cysts

BACKGROUND: The gold standard in the surgical treatment of simple renal cysts is laparoscopic cyst fenestration. However, laparoscopic procedures have disadvantages which include poor ergonomics of the instruments hindering surgeon's work in children's small abdomen. Robot-assisted surgery has the potential to make surgeon's work easier and to improve surgical outcomes in patients with kidney cysts for the instruments have seven degrees of freedom, hand tremor is filtered. It also promotes comfortable console positioning for the surgeon, and three-dimensional wide-angle imaging of the surgical field. AIM: To present the first experience of applying robot-assisted surgery for fenestration (decortication) of the outer portion of the cyst and argon-plasma coagulation of its inner lining. METHODS: The author's present retrospective data of all patients with simple renal cysts operated on with robot-assisted approach at the Irkutsk State Regional Children's Clinical Hospital. The diagnosis was put after ultrasound examination of kidneys and after computed tomography with intravenous contrast agent. Surgery was performed using a new model of the Versius robotic system manufactured by Cambridge Medical Robotics (UK). RESULTS: Patients' mean age at the time of surgery was (13±5.3) years (median 15 [11; 16] years), mean weight — (46.7±17.2) kg (median 54 [40.5; 56.5] kg), smallest body weight — 27 kg, size of cysts — (1.8±2.4) cm (median 0.4 [0.4; 2.5] cm). Cystic formations in all patients were located on the left: in the upper pole in 2 patients, in the lower pole in 1 patient. During the surgical intervention, there were no complications in the form of bleeding from the kidney parenchyma or damage to neighbouring organs. Histological analysis revealed that the lining of the cyst wall contained transitional epithelium without signs of malignancy. Duration of surgery was (136.7±72.2) min (median 95 [95; 157] min), duration of patients' stay in the intensive care unit — (19.9±2.5) hours (median21.3 [19.1; 21.4] hours), duration of hospital stay — (9.3±2.3) days (median 8 [8; 10] days). Ultrasound examination made in 1, 3 and 6 months after the surgery revealed no signs of disease recurrence in the form of residual accumulation of fluid associated with kidney parenchyma. CONCLUSION: The experience described in the article is encouraging and confirms the reasonability and safety of robot-assisted procedures in pediatric urology.

Comparing outcomes of prepectoral, partial muscle-splitting subpectoral, and dual-plane subpectoral direct-to-implant reconstruction: implant upward migration and the pectoralis muscle.

Although dual-plane subpectoral breast reconstruction has been widely implemented in implant-based breast reconstruction, animation deformities remain an issue. Recent advances in skin flap circulation detection have increased the use of prepectoral reconstruction. A partial muscle-splitting subpectoral plane was introduced to decrease the visibility of the implant edge. However, there is yet to be a direct comparison of these methods for optimal results, including changes in implant position after reconstruction. This study aims to compare the incidence of complications such as rippling, animation deformity, implant upward migration between the dual-plane, the partial muscle splitting subpectoral and the prepectoral reconstruction group. In addition, multivariate analysis was conducted to identify the risk factors of complications. We retrospectively investigated 349 patients who underwent unilateral direct-to-implant breast reconstruction from January 2017 to October 2020. Implants were inserted into the dual-plane subpectoral (P2) or partial muscle-splitting subpectoral (P1, the muscle slightly covering the upper edge of the implant) or the prepectoral pocket (P0). Postoperative outcomes and at least 2 years of follow-up complications were compared. There was no significant difference in rippling (P=0.62) or visible implant edges on the upper pole (P=0.62) among the three groups. In contrast, the P0 group had a lower incidence of seroma (P=0.008), animation deformity (P<0.001), breast pain (P=0.002), and upward implant migration (P0: 1.09%, P1: 4.68%, P2: 38.37%, P<0.001). According to the multivariate analysis, P2 resulted in a greater risk of seroma (odds ratio: 4.223, P=0.002) and implant upward migration (odds ratio: 74.292, P<0.001) than did P0. P0 and P1 showed better postoperative outcomes than P2. Additionally, P0 had less implant migration than P1. Even though P1 minimally dissects the muscle, the location of the implant may change. Considering that muscle contraction can deteriorate symmetry and aesthetic results, the P0 method may be the most favorable.

Changes in Microwave Ablation Zone Dimensions after Transarterial Embolization in an Ex Vivo Human Kidney Perfusion Model

PurposeTo utilize a novel ex vivo perfused human renal model and quantify microwave ablation (MWA) size differences in renal tissue when combining MWA with transarterial embolization (TAE). Materials and MethodsHuman kidneys (n = 5) declined for transplantation were obtained and connected to a fluoroscopy-compatible ex vivo perfusion system. Two ablations—1 standard MWA and 1 TAE-MWA—were performed in each kidney for 2 minutes at 100 W using a MWA system (Solero Angiodynamics). MWA alone was performed in the upper pole. In the lower pole, MWA was performed after TAE with 40–90 μm radiopaque microspheres to achieve angiographic stasis. Ablation zones of coagulative necrosis were sectioned along the long axis and segmented for maximal short-axis diameter (SAD) and long-axis diameter (LAD) measurements. ResultsA total of 10 ablations (5 MWAs and 5 TAE-MWAs) were performed in 5 human kidneys. TAE-MWA resulted in significantly increased SAD, LAD, volume, and sphericity compared with standard MWA ± SD, with mean measurements as follows (5 standard MWAs ± SD vs 5 TAE-MWAs ± SD, 2-tailed t-test): (a) SAD, 1.8 cm (SD ± 0.1) versus 2.5 cm (SD ± 0.1) (P < .001); (b) LAD, 2.9 cm (SD ± 0.3) versus 3.2 cm (SD ± 0.1) (P = .039); (c) volume, 5.0 mL (SD ± 0.5) versus 11.0 mL (SD ± 0.7) (P < .001); and (d) sphericity, 0.4 (SD ± 0.2) versus 0.6 (SD ± 0.1) (P = .049). Histology demonstrated no differences in TAE-MWA other than concentrated microspheres. ConclusionsThis ex vivo human kidney perfusion model confirmed that combined MWA-TAE significantly increased ablation size and spherical shape compared with MWA alone.

Comparison of supine-prone percutaneous nephrolithotomy methods in the treatment of kidney stones in pediatric patients: prospective randomized study.

Mini-PCNL is one of the most effective surgical methods in the treatment of kidney stones in pediatric patients. In this study, we aimed to compare PCNL in the supine-prone position in pediatric patients (especially operation time, postop complications, hospital stay and stone-free rates).We conducted our study in a randomized and prospective manner. Patients with lower pole stones larger than 1cm, stones larger than 1.5cm in the pelvis, upper pole, midpole or multiple locations, and patients who did not respond to ESWL or whose family that preferred mini-PCNL to be the primary treatment were included in the study. Patients with any previous kidney stone surgery, patients with coagulation disorders and patients with retrorenal colon were excluded from the study. Between 2021 and 2023, a total of 144 patients underwent PCNL. 68 of these patients had supine PCNL and 76 prone PCNL. Postoperative Clavien grade1 complication occurred in a total of 7 patients in the prone position; Clavien grade1 complication occurred in 1 patient in the supine position. The mean operation time for prone PCNL was 119.88 ± 28.32min, and the mean operative time for supine PCNL was 98.12 ± 14.97 the mean hospitalization time in prone PCNL was 3.56 ± 1.12days, and 3.00 ± 0.85days in supine PCNL. In conclusion, supine PCNL is a safe and effective method in the treatment of pediatric kidney stones and postoperative complications were observed to be less; the operation time and hospital stay were shorter in supine PCNL.

(244) Optimization of Sperm Retrieval in Non-Obstructive Azoospermic Patients using Conventional TESE

Abstract Introduction Sperm retrieval in NOA patients remain to be the only hope for these patients for fatherhood using assisted reproductive techniques. Micro-TESE is the gold standard with the best retrieval rate. Microsurgical facilities are not available at every center and conventional TESE techniques are not standardized between different centers. Objective Our aim is To improve the spermatogenic function of NOA patients to enable the appearance of sperm in their ejaculate or to improve the chances of a successful retrieval from the testis for ICSI and To optimize and standardize our conventional TESE technique Methods Over last 7 years 94 cases of NOA patients were subjected to conventional TESE. We Exclude the cases of Obstructive Azoospermia, Cases with abnormal chromosomal analysis were referred for higher center for genetic counselling and diagnosis. Laboratory workup including at least two semen samples, hormonal valuation (FSH, LH, Prolactin, Testosterone) and chromosomal analysis (Karyotyping and Testing for Y chromosome micro-deletions. Pre-TESE medical Treatment: included Clomiphene citrate: 50 mg OD for 3–6 months, Anti-oxidant therapy (Vitamin E 200mg BID and Vitamin C, 1 gm, OD). 6 biopsies from each testis: upper pole 2(medial &amp;Lateral), mid zone 2 (medial &amp; Lateral), lower pole 2(medial &amp;Lateral). Separate biopsy from each testis was sent for definitive histopathological correlation. Experienced embryologist attends each procedure examining each biopsy until sperms are retrieved. Samples taken were centrifuged and re-examined at lab for any missed sperm Results sperm retrieval was successful in 38patients (40.4%). All cases were done as day case No single case of wound infection or intra-testicular hematoma.Post-operative pain was tolerable and managed by paracetamol ±NSAID Negative cases for sperms were continued on higher dose of CC and referred for microTESE Conclusions Though of low-evidence, empiric Pre-TESE enhancement of spermatogenesis should be attempted whenever possible and after proper patients counselling. This systematic anatomical approach for biopsies yielded high SRR compared to other conventional TESE. Exact localization of + ve testicular site and side If patient needed Re-do TESE for more sperms in the future. Although micro TESE remains to be the best modality for SR in NOA, in our hands and in canters without Micro-TESE facilities, applying this standardized technique with pre-operative hormonal manipulation yields accepted rate of sperm retrieval Disclosure No.

Is the nodule location a predictive risk factor for cancer in AUS/FLUS thyroid nodules? A retrospective cohort study

Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is a heterogeneous category of thyroid nodules with uncertain cytology and controversial management. This study aimed to assess the association between nodule location and malignancy risk and whether the location can be used as a predictive risk factor for cancer in AUS/FLUS nodules. A cohort of 102 patients (79 [77.5%] women, 23 [22.5%] men) was retrospectively analyzed. Only patients with a final histopathology of benign or well-differentiated thyroid cancer and an available nodule location were included. Sociodemographic, histopathological, and sonographic data were statistically evaluated and correlated. Based on pathology findings, 54 (52.9%) and 48 (47.1%) nodules were benign and malignant, respectively. Most nodules were right-sided (54.9%). Considering the nodule location, 41.2% of nodules occupied the whole lobe, 20.6% only the lower pole, 15.7% only the upper pole, and 2.9% the isthmus. Cases with nodules occupying only the upper, middle, or lower pole showed significant associations with cancer risk (odds ratio, [95% confidence interval]: 2.6, [1.1-5.7]; 2.0, [1.0-4.7]; and 1.9, [1.0-3.9], respectively). Male sex and the presence of a peripheral halo were significantly associated with malignancy risk (3.3, [1.2-9.1], P=0.014; and 2.7, [1.0-9.5], P=0.049, respectively). Isthmic nodules had the highest malignancy level (66.7%). Nodule location is a promising predictor of malignancy in AUS/FLUS nodules. Furthermore, isthmic nodules had the highest malignancy level, emphasizing the significance of careful evaluation of these nodules. Further large prospective studies are required to confirm these findings.

FAM-Fat Augmentation Mastopexy: A Method to Avoid Implants.

Despite high complication rates, patients persistently present for single-stage augmentation mastopexy. In empty, deflated breasts, we perform one-stage augmentation mastopexy; however, in heavy ptotic breasts, our preference is to stage the procedure with mastopexy and fat graft first. With volume from fat grafting focussing on the upper pole and cleavage areas, many of our patients avoid implants altogether. This reduces subsequent risks of waterfall deformity, implant displacement, rupture and a lifetime of implant exchanges. We aim to describe our findings and technique for reducing progression to the second stage of a two-stage augmentation mastopexy with the appropriate use of moderate to high volume of fat grafting at the primary operation. This is a retrospective review of all patients who presented to the senior author (KT) requesting breast implants and requiring mastopexy, from January 2018 to December 2022. Over the five-year period, 137 patients were identified. Seventy-one (51.8%) underwent single-stage augmentation mastopexy, 55 (40.1%) underwent mastopexy with fat grafting and 11 (8.0%) underwent mastopexy with no fat grafting. Our key finding in this study is that 52 of 66 (78.8%) of planned staged patients, who underwent mastopexy with or without fat grafting, were happy with the volume attained and no longer wished to undergo further implant augmentation. In selected patients, appropriate volume and position of fat grafting at the time of primary mastopexy can significantly obviate the need for a second stage implant (alloplastic) augmentation. 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 .

A gradient model of renal ischemia reperfusion injury to investigate renal interstitial fibrosis.

Background: The progression from acute kidney injury to chronic kidney disease poses a significant health challenge. Nonetheless, a constraint in existing animal models of renal ischemia/reperfusion (I/R) injury is the necessity for a severe injury, almost reaching a life-threatening level, to trigger the subsequent onset of renal fibrosis. Hence, we explored an adapted gradient approach to induce I/R injury, aiming to promote the progression of renal fibrosis while preserving the overall normal functioning of the kidney. Methods: In each group, 6-8 male C57BL/6 mice were used for model construction, with all undergoing sodium pentobarbital anesthesia and left kidney removal. Subsequently, a silk thread was passed beneath the lower renal branch, elevating the right kidney under a 20-g weight's tension via a pulley system for durations of 30, 40, or 60min. Afterwards, we lowered the kidney, sutured the wound, and administered intraperitoneal saline. Mice in different groups were euthanized following reperfusion for 1, 3, 7, or 28days. Results: We observed a complete cessation of blood flow in the lower pole, while an incomplete cessation in the upper pole in the elevated kidney. Significant renal impairment was evident on day 1 with a 60min ischemic period (187.0 ± 65.3 vs 17.9 ± 4.8μmol/L serum creatinine in normal; p < .001), but not with 30 or 40min. On day 1, tubular necrosis and hyaline cast formation was evident in both lower and upper poles. On day 3, renal function returned to normal and remained normal through day 28. Histologic damage resolved in the upper pole over days 3 to 7, resulting in normal histology on day 28. By contrast, there was sustained tubular damage tubular in the lower pole on days 3 and 7, which failed to resolve and led to significant renal fibrosis by day 28. Conclusion: We created a model demonstrating clinically "silent" renal fibrosis.

Factors effecting the success of retrograde intrarenal surgery in pediatric patients with renal stones: The experience of two tertiary centres with 368 renal units

Currently, in the field of pediatric urology, the primary aim of surgical approaches for the treatment of renal stone disease is to provide a stoneless state through minimally invasive methods, and to prevent the damage that such stones may cause in the urinary system and stone recurrence. The aim of this study was to evaluate the efficacy and safety of RIRS and the factors affecting its success in the surgical treatment of renal stones in pediatric patients. Data from 357 pediatric and 368 renal units were collected retrospectively. The recorded parameters were age, gender, location and burden of the stone, and presence of postoperative residual stones. The stone location was the upper pole in 28 (7.6%) patients, the middle pole in 44 (12%), the pelvis in 98 (26.6%), the lower pole in 139 (37.8%), and multiple locations in 59 (16%) patients. A stoneless state was achieved in 277 (75.3%) units, while 91 units (24.7%) had residual stones at the end of the first month. In the multivariate analysis, the development of residual stones was found to be significantly associated with age (odds ratio [OR], 1.123; p=0.012) and stone location (OR, 3.142; p=0.018). RIRS is an endourological procedure with a high success rate in the achievement of a stoneless state in both pediatric and adult age groups, with an 82-100% success rate reported in various studies. A full stoneless state was achieved in 277 (75.3%) units after the initial RIRS in the present study, and full stone clearance was achieved in 304 units after the second RIRS session, with a success rate of 82.6%. A limitation of our study is that it was not performed by a single surgeon, and stone samples could not be taken from all patients for stone analysis. RIRS has also been associated with a high success rate in the endoscopic treatment of renal stones and is an efficient and safe method with a minimal rate of complications, especially in the pediatric age group.

Shear wave elastography of kidneys in children: utility in distinguishing steroid-resistant and steroid-sensitive nephrotic syndrome.

To assess the renal elasticity values using (SWE) and correlate the values with steroid sensitivity to distinguish between steroid-resistant nephrotic syndrome (SRNS) and steroid-sensitive nephrotic syndrome (SSNS) in children. In this IRB-approved cross-sectional study, 83 children (4-14years) diagnosed with nephrotic syndrome were included from July 2021 to December 2022. SWE measurements were done for each kidney's upper pole, interpolar region, and lower pole. Mean as well as median SWE were calculated. Correlation of the renal stiffness values was done with different laboratory findings (blood urea, serum creatinine, 24h urine protein, serum albumin, and serum cholesterol), the grayscale findings (cortical echogenicity, and corticomedullary differentiation), and the final diagnosis of SRNS and SSNS. The statistical tests were done at a significance level of α = 0.05. The median (IQR) overall SWE of kidneys was higher in SRNS group 12.64 (8.4-19.68) kPa than SSNS group 9.87 (8.20-12.56) kPa. The difference was significant (p = 0.004). At a cut-off of ≥ 10.694kPa (AUROC- 0.641), the overall SWE predicted SRNS group with a sensitivity of 70% and a specificity of 63%. A significant correlation (p < 0.05) was found between the SWE and 24-h urine protein, cortical echogenicity, and corticomedullary differentiation in SSNS, while only between SWE and corticomedullary differentiation in SRNS. The mean SWE was higher in children with SRNS. While SWE has potential to differentiate SSNS from SRNS, a different study design where SWE is performed at presentation is needed for confirmation.

Co-existence of Morgagni’s cyst with a twisted vas aberrans and “bell clapper” deformity in a 15-year-old boy: a case report

BackgroundThe testicular appendix is a residual of the paramesonephric and mesonephric duct, most commonly found close to the superior pole of the epididymis as Morgagni’s cyst. Torsion of such cysts is a common event in children, and the patient usually presents with a palpable testis with a tender mass in its upper pole. The co-existence of two or more appendices is very rare. In addition to the fact that Morgagni’s cyst was the non-twisted one and vas aberrans was, made clinical and radiological diagnosis difficult.Case presentationOur patient, a 15-year-old boy, presented with persistent pain in the right scrotum, a significant palpable mass accompanied by vomiting. Upon surgical exploration, a large dark cyst was found located on the right side of the right testicle with a 720-degree torsion. The cyst was straightened and excised along with a Morgagni’s cyst. The testis was fixed in the right hemiscrotum due to a “bell clapper” deformity that was also a finding.ConclusionsPathological findings were consistent with a twisted cyst of a testicular appendix (vas aberrans). Co-existence of two or more appendices is very rare in addition to the fact that Morgagni’s cyst was the non-twisted one. Usually and in very few cases, a second appendix is found randomly, during surgical exploration for acute scrotum due to torsion of Morgagni’s cyst.

Supine mini percutaneous nephrolithotomy in horseshoe kidney.

The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre-operative and post-operative data, complications, and stone status after surgery. Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre- and post- operatively with non-contrast CT. we evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFr were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone-free or presence of ≤4 mm fragments (Clinically Insignificant residual Fragments - CIrF). Complications were registered and classified according to Clavien-dindo Grading System, during the 30 - day postoperative period and Clavien scores ≥ 3 were considered as major complications. Statistical analysis was performed using "r 4.2.1" software, with a 5% significance level. we also compared pre-operative and post-operative data using "wilcoxon signedrank test". No statistical difference was observed between preoperative and post-operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone-free rate: 90%), while 1/10 patients had ≤4 mm residual stone fragments (CIrF rate: 10%). No cases of intraoperative complications were registered. Post-operative complications were reported in 1/10 patients. A patient developed urosepsis (defined as SIrS with clinical signs of bacterial infections involving urogenital organs - Clavien-dindo Grade II) after procedure, and was treated with intravenous antibiotic therapy successfully. Conclusions: This study shows that in patients with HSK mini- PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.

Morphological Aesthetics Assessment of the Predicted 3D Simulation Results and the Actual Results of Breast Augmentation.

Although three-dimensional (3D) simulations are becoming more common in preoperative breast augmentation planning, this does not necessarily imply that the simulated results are highly accurate. We aimed to evaluate the accuracy of the 3D simulation technique by comparing the differences in breast morphology between the 3D prediction model and the actual results. The simulation and actual postoperative results of 103 patients who underwent breast augmentation were analyzed retrospectively. Therefore, a 3D model was created, and the parameters of line spacing, nipple position, breast projection, surface area, and volume were evaluated. Furthermore, consider the difference in chest circumferences and breast volume. In comparison with the simulation results, the actual results had a mean increase in the nipple to the inframammary fold (N-IMF) of 0.3cm (P < 0.05) and a mean increase in basal breast width (BW) of 0.3cm (P < 0.001), a difference that was not statistically significant in patients with larger breast volumes. There was a significant difference in the mean upper and lower breast volume distribution between simulated and actual breasts (upper pole 52.9% vs. 49.2%, P < 0.05, and lower pole 47.1% vs. 50.8%, P < 0.001). However, it was not statistically significant in patients with larger chest circumferences. Our study shows that 3D simulation has uncertainties related to the patient's chest circumference and breast volume. Therefore, these two critical factors must be considered when using simulation assessment in preoperative 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 .

Renal artery aneurism and renal autotransplantation: review of surgical technique, preoperative complementary examinations and postoperative follow-up protocol

Introduction: Renal artery aneurysm (RAA) is a rare pathology; however, its incidental diagnosis is increasingly frequent due to the increasing use of imaging techniques. Complex (hilar) RAAs, dependent on the distal renal artery and its branches, constitute a subset of RAAs that present a therapeutic challenge due to their anatomical location and may require extracorporeal arterial repair and autotransplantation. Material and methods: A bibliographic review is carried out to homogenize the management of this pathology, analyzing the indications for surgical treatment, the recommended surgical technique step by step, as well as post-surgical monitoring. Two clinical cases of RAA treated in our center by hand-assisted laparoscopic nephrectomy, ex vivo bench repair and renal autotransplantation are presented. Results: In both cases, a postoperative Doppler ultrasound of the graft was performed 24 hours later, in which a renal graft was observed in the iliac fossa, of normal size and cortical thickness within normality with normal color Doppler signal, and spectral curves without alterations. Both patients presented oligoanuric acute renal failure (injury) during the immediate postoperative period (first 24 hours) with complete resolution at discharge, which occurred on the 11th and 12th postoperative day, respectively. In both patients a diuretic renogram with MAG3 was performed. In case 1, it was performed the third postoperative month and a slightly ectatic right kidney was observed with less perfusion and parenchymal incorporation of the radiotracer, with a reduction in relative renal function (39.47%) and MAG3 clearance (indeterminate renographic pattern). In this patient, a CT scan with the excretory phase was performed simultaneously, in which a grafted right kidney was seen at the level of the right iliac fossa with good contrast elimination in the excretory phase bilaterally and symmetrically. A small non-perfused area is observed in the upper pole. In the second patient, the renogram was performed on the 14th postoperative day, finding the morphofunctional study of the graft within normal parameters without detecting areas of hypoperfusion. The levels of creatinine and glomerular filtration were, respectively, in the first case: 0.86mg/dl and 90.19ml/min/1.73m2 preoperatively and 0.83mg/dl and 90.96ml/min/ 1.73m2 per postoperative month. In the second case, the values were: preoperatively creatinine of 0.66mg/dl and glomerular filtration rate of 97.96ml/min/1.73m2 and 0.81mg/dl and 89ml/min/1.73m2 one month postoperatively. Conclusion: After reviewing the literature, there is no consensus regarding the imaging techniques to be performed after renal autotransplantation and the optimal time frames for performing these for the evaluation of the postoperative graft. There is also no homogeneity in the imaging techniques to be performed in the preoperative assessment. In our experience, open ex vivo surgical repair of complex distal hilar RAAs has been successful with low morbidity and mortality and an acceptable rate of preservation of renal function.

Comprehensive analysis of clinicopathologic and sonographic features in thyroid cancer with skip lymph node metastasis: establish and assessment of a prediction nomogram

Lateral Lymph Node Metastasis (LLNM) is common in Papillary Thyroid Carcinoma (PTC) and is associated with a poor prognosis. LLNM without central lymph node metastasis as skip metastasis is not common. We aimed to investigate clinicopathologic and sonographic risk factors for skip metastasis in PTC patients, and to establish a nomogram for predicting the possibility of skip metastasis in order to determine the therapeutic strategy. We retrospectively reviewed the data of 1037 PTC patients who underwent surgery from 2016 to 2020 at a single institution. Univariate and multivariate analyses were used to identify the clinicopathologic and preoperative sonographic risk factors of skip metastasis. A nomogram including the risk factors for predicting skip metastasis was further developed and validated. The incidence of skip metastasis was 10.7%. The univariate and multivariate analyses suggested that gender (p= 0.001), tumor location (p= 0.000), extrathyroidal extension (p= 0.000), and calcification (p= 0.000) were independent risk factors. For papillary thyroid microcarcinoma, tumor location (p= 0.000) and calcification (p= 0.001) were independent risk factors. A nomogram according to the clinicopathologic and sonographic predictors was developed. The receiver operating characteristic curve indicated that AUC was 0.824 and had an excellent consistency. The calibration plot analysis showed a good performance and clinical utility of the model. Decision curve analysis revealed it was clinically useful. A nomogram for predicting the probability of skip metastasis was developed, which exhibited a favorable predictive value and consistency. For the female PTC patient, tumor located at the upper pole is more likely to have skip metastasis. Surgeons and sonographers should pay close attention to the patients who have the risk factors.Evidence level: This article’s evidence level is 3. Level 3 evidence is derived from non-randomized, controlled clinical trials. In this study, patients who receive an intervention are compared to a control group. Authors may detect a statistically significant and clinically relevant outcome.

Primary lipofilling as an adjunct in transverse upper gracilis flap breast reconstruction

In many centres, the myocutaneous transverse upper gracilis (TUG) flap represents an alternative choice in autologous breast reconstruction when abdominal tissue is unavailable. However, a single TUG flap may be volume deficient, particularly in the upper pole. We describe the application of simultaneous lipofilling to the pectoralis major muscle at the index procedure and present our decision-making algorithm, technique and outcomes. A retrospective review of all TUG flaps between January 2011 and May 2021 was conducted. Patient demographics, volume of primary and any subsequent fat grafting and complications were recorded. A total of 183 patients (242 TUG flaps) were included in this study. Of these; 130 patients were reconstructed with single TUG flaps, 16 patients received a single TUG flap with immediate lipofilling, and 37 patients underwent stacked, double TUG flap reconstructions. Of the 242 flaps, there were 2 flap losses (<1%), neither of which occurred in the immediate lipofilling cohort. Among the 130 single TUG patients, 28 (21.5%) required a cumulative total of 40, and a mean of 1.4, secondary lipofilling procedures. The immediate lipofilling patients were injected with a mean of 42ml fat (range: 20-80ml). In this group, only 2 of 16 patients required secondary lipofilling. The mean follow-up was 67 months (17-141). Primary lipofilling may reduce the need for secondary revisional procedures and appears safe at the index operation, adds little operative time and has negligible donor site morbidity. In patients where a second (stacked) flap would add unnecessary volume and complexity, it can be considered a useful adjunct.

2D Shear wave elastography for evaluation of renal cortex and medulla: stiffness values in healthy children.

To evaluate renal cortical and medullary stiffness using 2D Shear-wave elastography (SWE) in healthy children. In this IRB approved prospective study, we measured the stiffness of cortex and medulla of children (4months-17years) at the upper pole, mid pole, and lower pole in bilateral kidneys. The median (IQR) values of renal cortex in <1year age group was 8.7 (5.7-11.7) kPa for right and 8.7 (4.2-14.1) kPa for the left side. For 1-5years age group, it was 7.3 (5.3-10) kPa for the right and 8.9 (6-12.3) kPa for the left side. For >5years, it was 7.4 (5.3-11.2) kPa for the right and 9.6 (6.2-12.7) kPa for the left side. The median (IQR) values of renal medulla in <1year age group was 7.1 (5.1-12.5) kPa for right and 6.8 (4-10.6) kPa for the left side. For 1-5years age group, it was 7.2 (4.9-9.7) kPa for the right and 6.9 (5.6-9.9) kPa for the left side. For >5years, it was 6.8 (5.1-9.6) kPa for the right and 7 (5-10.2) kPa for the left side. The differences in the elasticity values amongst these groups were statistically insignificant (p>0.05). There was a significant correlation between SWE values of cortex and medulla of right kidney (ρ=0.64) and of left kidney (ρ=0.61), respectively. SWE values of renal cortical and medullary stiffness in healthy children do not correlate with age. There is a significant correlation between SWE values of cortex and medulla of the kidneys in healthy children.