Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation – An anatomical study

Introduction

The antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve.

Methods

13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve.

Results

The mean distance of the nerve from the anterolateral acromion was 62 mm (range 45–81 mm). The nerve lay closest to the distal blade fixation screw 4.9 mm (range 0–19 mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8 mm (range 0–3 mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer.

Conclusion

The anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken.     

Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal – Is it really necessary?

Introduction

Syndesmotic disruption can occur in up to 20% of ankle fractures and is more common in Weber Type C injuries. Syndesmotic repair aims to restore ankle stability. Routine removal of syndesmosis screws is advocated to avoid implant breakage and adverse functional outcome such as pain and stiffness, but conflicting evidence exists to support this. The aim of the current study is to determine whether functional outcome differs in patients who had syndesmosis screws routinely removed, compared to those who did not, and whether a cost benefit exists if removal of screws is not routinely necessary.

Patients and methods

A retrospective review of consecutive syndesmosis repairs was performed from 1 January 2008 to 31 December 2010 in a single regional trauma centre. We identified 91 patients who had undergone open reduction internal fixation of an ankle fracture with placement of a syndesmosis screw at index procedure. As many as 69 patients were eligible for the study as defined by the inclusion criteria and they completed a validated functional outcome questionnaire.The functional outcomes of patients with ‘retained screws’ and ‘removed screws’ were analysed and compared using the Olerud Molander Ankle Score (OMAS).

Results

A total of 63 patients responded with a mean follow-up period of 31 months (range 10–43 months). Of those patients, 43 underwent routine screw removal whilst 20 had screws left in situ. The groups were comparable considering age, gender and follow-up time. The ‘retained’ group scored higher mean OMAS scores, 81.5 ± 19.3 compared to 75 ± 12.9 in the ‘removed’ group (p = 0.107). The retained group achieved higher functional scores in each of the OMAS domains as well as experiencing less pain. When adjusted for gender, the findings were found to be statistically significant (p = 0.046).

Conclusion

Our study has shown that retained-screw fixation does not significantly impair functional capacity, with additional cost-effectiveness. We therefore advocate that syndesmosis screws be left in situ and should only be removed in case of symptomatic implants beyond 6 months postoperatively.     

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: A level-one trauma-centre experience

Purpose

This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography.

Methods

From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented.

Results

Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18–66) with 62.5% mean probability of survival (6.8–98.8%). The mean operating time for RPP was 23 mins (20–35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation.

Conclusion

Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.     

A new surgical approach of temporary ovarian transposition for children undergoing brachytherapy: Technical assessment and dose evaluation

Purpose

We developed a new technique of temporary ovarian transposition (OT) for prepubertal girls undergoing brachytherapy. The aim of this study was to describe it, assess its feasibility and safety and calculate the dose delivered to the ovary in order to prove its efficacy.

Methods

Sixteen prepubertal patients underwent temporary OT for brachytherapy at our center from March 2001 to December 2012. OT was done either by laparotomy or by laparoscopy. In all patients, the ovaries were grasped with an atraumatic forceps and mobilized above the iliac crest level as high as possible without any dissection or division of the ovarian ligaments or of the fallopian tube. They were sutured to the anterior abdominal wall by a transfixing stitch of non-dissolvable suture knotted on the outside of the patient on a pledget.

Results

Median age at surgery was 3 years (range: 2–9 years). The integrity of the fallopian tube was respected and not a single ligament was dissected or divided. None of the patients had intraoperative or postoperative complications. The stitches were retrieved after completion of irradiation and the ovaries in all the patients fell back into the pelvis. The calculated median radiation dose to the ovary was 1.4 Gy (range: 0.4–2.4 Gy).

Conclusions

This surgical technique is simple and safe, either by laparotomy or by laparoscopy. It meets the radiation and physical constraints in prepubertal girls with vaginal or bladder RMS. However, longer follow-up is required to assess the ovarian function.     

Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience

Background

Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands.

Objective

To describe our technique of transvesical robotic simple prostatectomy (RSP).

Design, setting, and participants

From May 2011 to April 2013, 25 patients underwent RSP.

Surgical procedure

We performed RSP using our technique.

Outcome measurements and statistical analysis

Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed.

Results and limitations

Mean patient age was 72.9 yr (range: 54–88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9–35), prostate volume was 149.6 ml (range: 91–260), postvoid residual (PVR) was 208.1 ml (range: 72–800), maximum flow rate (Q_max) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9–56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165–345), estimated blood loss was 143 ml (range: 50–350), and the hospital stay was 4 d (range: 2–8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p < 0.0001), an 82.2% reduction in mean PVR (p = 0.014), and a 77% increase in mean Q_max (p = 0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation.

Conclusions

Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures.

Patient summary

We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.     

Eraser Laser Enucleation of the Prostate: Technique and Results

Background

Eraser, a 1318-nm diode laser, has been used for 15 yr for resection of lung metastases. It was recently introduced in urology for small kidney tumors and for the treatment of benign prostatic obstruction.

Objective

To demonstrate on video our technique of Eraser laser enucleation of the prostate (ELEP) and report our experience.

Design, setting, and participants

From June 2010 to October 2011, 43 consecutive patients were prospectively evaluated. All of them had lower urinary tract symptoms suggestive of benign prostatic obstruction and a mean prostate size of 59.9 ml (range: 34–89 ml) on transrectal ultrasound. Their mean prostate-specific antigen value was 3.4 ng/ml (range: 0.8–5.0 ng/ml); mean maximum flow rate (Q_max), 6.9 ml/s (range: 2–11 ml/s); mean International Prostate Symptom Score (IPSS), 25.9 (range: 18–32); and mean postvoid residual (PVR), 170.5 ml (range: 60–330 ml).

Surgical procedure

The details of the technique are shown on video.

Outcome measurements and statistical analysis

Success was defined as patients being able to void with improved IPSS, Q_max, PVR volume, and ameliorated quality of life.

Results and limitations

The mean operating time was 67.0 ± 11.43 min. Mean serum hemoglobin was 15.1 ± 0.87 g/l before, and 14.39 ± 0.94 g/l after surgery. Mean blood loss was 115.90 ± 98.12 ml. No blood transfusions were required. All patients had their catheters removed within 2 d and were able to void spontaneously after this time. Significant improvements were noted in Q_max, quality of life, IPSS, and PVR volume from baseline to each follow-up time point.Based on the validated Clavien-Dindo system, we observed one grade 1d complication, one grade 2 complication, and one grade 3b complication.

Conclusions

ELEP is a safe and reproducible method for relieving bladder outflow obstruction and lower urinary tract symptoms. Its advantages include minimal blood loss, short catheterization time, and a brief hospital stay.     

Experience with FiberWire for pectus bar attachment

Background

Minimally invasive repair of pectus excavatum has become an established method for repair of pectus excavatum. Bar displacement or rotation remains the most common complication of this repair requiring return to the operating room.

Methods

Retrospective review of all patients at a single institution who underwent repair of pectus excavatum using FiberWire for bar stabilization between December 2009 and March 2013 was undertaken.

Results

93 patients underwent minimally invasive pectus repair using FiberWire during the study period. The patients included 73 males and 20 females, with an average age of 14.6 years (range 7–21 years). Mean operative time was 102 minutes (range 56–198 minutes). No patients developed wound complications, two patients developed pain because of bar migration and required return to the OR, and no patients had recurrence of their pectus defect because of bar migration during the study period. Median length of follow-up was 17 months (range 3–36 months).

Conclusion

Stabilization of pectus bars using circumferential rib fixation with FiberWire at multiple points on both sides of the bar appears to be effective in preventing bar rotation and displacement, and requires minimal change to the operation as it has been previously described. Early experience shows a low rate of complications.     

Laparoscopic Surgical Complete Sling Resection for Tension-Free Vaginal Tape–Related Complications Refractory to First-Line Conservative Management: A Single-Centre Experience

Background

Tension-free vaginal tape (TVT) has been largely used for the management of stress urinary incontinence. In certain cases, however, this procedure results in bothersome complications that lead to a complete resection.

Objective

We assessed the technical feasibility and functional outcome after complete laparoscopic resection of TVT.

Design, setting, and participants

Thirty-eight women with TVT-related complications refractory to first-line management underwent a complete laparoscopic tape resection between 2001 and 2009.

Surgical procedure

Complete laparoscopic resection was achieved with either an intra- or extraperitoneal laparoscopic approach. Laparoscopy was performed with four ports: a 10-mm umbilical telescope port, two 5-mm ports placed medially to the anterior superior iliac spines, and a 10-mm port placed at the midpoint between the pubis and umbilicus. The two half-tapes were dissected towards the urethra and removed.

Measurements

All data referring to patient demographics, surgery, tape-related complication, and perioperative outcomes were recorded.

Results and limitations

The mean age of the patients was 66.2 yr (range: 45–79 yr). TVT-related complications included bladder erosion, vaginal extrusion, and bladder outlet obstruction or groin pain. The resection took place at a mean time of 25 mo (range: 6–80 mo) after TVT placement. Resection was complete in all patients, within a mean operative time of 110 min (range: 50–240 min). All women reported a total decrease of symptom-related complications within a mean follow-up period of 37.9 mo (range: 2–80 mo). However, recurrent incontinence occurred in 65.7% (n = 25) of the patients. The main limitation of the study was the lack of a validated questionnaire to assess the evolution of functional disorders.

Conclusions

Complete laparoscopic resection of TVT is safe and technically feasible. In the limited number of women who have persisting disabling symptoms after conservative management, urologists must be aware that a complete resection can help resolve the symptoms.     

Novel technique of reduction of a chronic atlantoaxial rotatory fixation using a temporary transverse transatlantal rod

Background context

Chronic atlantoaxial rotatory fixation (AARF) is uncommon as acute AARF is easily reduced either spontaneously or by conservative methods. Various anterior and posterior surgical approaches for a chronic AARF have been reported because of the difficulty encountered in obtaining reduction.

Purpose

To describe a novel technique of reduction of a chronic AARF using a temporary transverse transatlantal rod.

Study design

Technical report.

Methods

A 13-year-old girl presented with an 8-month-old chronic AARF with typical torticollis and “cock-robin” posture of the head with a normal neurology. As closed reduction with skull traction for 2 weeks failed to reduce the deformity, the patient underwent C1–C2 fusion. C1 lateral mass and C2 pedicle screws were inserted under computer navigation. A temporary transverse rod across the atlas and axis was placed to secure a three-column fixation to derotate the subluxed atlas into anatomical alignment. Rods were then connected between the C1 lateral masses and the C2 pedicle screws and fusion obtained with autologous iliac crest grafts.

Result

Anatomic reduction of the atlantoaxial region was obtained without neural compromise, and satisfactory fusion was observed at 6-months follow-up.

Conclusion

A temporary transatlantal rod provides a secure anchor point for easy maneuverability for reduction of a chronic AARF and has the advantage of being used even in the absence of the posterior arch of the atlas.     

Laparoscopic pneumovesical ureteral tapering and reimplantation for megaureter

Objective

To evaluate the efficacy of laparoscopic pneumovesical ureter reimplantation for congenital malformation involving the vesicoureteral junction in children.

Methods

From January 2005 to October 2010, 45 cases (comprising 61 ureters) were diagnosed as megaureter caused by vesicoureteral junction obstruction. A pneumovesical laparoscopic Cohen procedure was performed in all cases. Twelve of the ureters underwent excisional ureteral tapering. Ureteral diameters were obtained using ultrasonography and were divided into 4 groups according to the degree of dilatation.

Results

The procedure was completed in all but 2 patients, who were converted to open surgery. The mean operation time was 3.5 h (range, 2–8 h) for unilateral ureter cases, 3.7 h (range, 3.5–4.5 h) for duplicated ureter cases, and 5.4 h (range, 3.5–9 h) for bilateral cases. The mean duration of urethral catheter placement and hospital stay was 6.7 days (range, 3–14 days) and 8.3 days (range, 4–15 days), respectively. Thirty-five of the patients (48 ureters) were followed up by ultrasonography for 1–67 months (mean, 19.3 months). Ultrasound scans revealed improvement in the degree of dilatation of 32 ureters. In 1 patient, the ultrasound scan showed deterioration of ureteral dilatation. This patient developed stenosis at the neoureteral opening and underwent reoperation 6 months later. Fourteen patients were followed up by micturating cystourethrogram (MCU).Of these, 3 cases (4 ureters) exhibited reflux (2 unilateral cases of grade 1 reflux and grade 3 reflux, respectively, and 1 bilateral case of bilateral grade 1 reflux).

Conclusions

Pneumovesical ureteral reimplantation for vesicoureteral junction obstruction is feasible and effective. In this series, ultrasound scans showed improvement in most ureteral dilatation cases on follow-up.     

Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem

Purpose

This study was designed to compare the outcome of two surgical approaches for treating femoral periprosthetic fractures around a stable femoral stem. The hypothesis was that plate fixation alone might be associated with a higher complication rate due to insufficient mechanical stability. We also considered that the addition of a strut allograft would contribute to fracture healing by means of osteoconduction.

Methods

We retrospectively assessed the outcome of 21 patients who sustained periprosthetic fractures around a total hip replacement system (Vancouver type B1 and type C fractures) and who were treated in our department (January 2006 and August 2011) either by plate fixation alone or by plate fixation and a strut allograft. The mean postoperative follow-up was 23 months (range 9–69 months). Eleven patients were treated by plate fixation alone (Plate Group), and 10 patients were treated by plate fixation and a deep frozen cortical strut allograft (AG Group). Functional outcome was rated by the Harris Hip scoring system. Postoperative radiographs were assessed for evidence of fracture union. Surgical failure was defined as any complication requiring surgical revision.

Results

The 21 patients included 17 females and 4 males. The average age was 79 years (range, 73–88) for the Plate Group and 82 years (range, 53–94) for the AG Group, and the average time to fracture union was 12 weeks (range, 2.5–6 months) and 12.95 weeks (range, 1.5–3) respectively. The overall failure rate was significantly higher in the Plate Group: 5 of them required revision surgery compared to none in the AG Group (p = 0.014).

Conclusion

The results of this analysis indicate that a strut allograft augmentation approach to Vancouver type B1 and type C periprosthetic fractures results in a better outcome than plate fixation alone by apparently adding mechanical stability and enhancing the biological healing process.     

Laparoscopic Approach for Artificial Urinary Sphincter Implantation in Women with Intrinsic Sphincter Deficiency Incontinence: A Single-Centre Preliminary Experience

Background

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

Objective

To assess the early functional outcome after laparoscopic placement of an AUS in women.

Design, setting, and participants

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

Intervention

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

Measurements

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

Results and limitations

The mean age of subjects was 56.7 ± 12 yr (33–78). The mean body mass index was 24 ± 2.3 (20–25). The mean preoperative closure pressure was 22 ± 10.9 cmH₂O (4–35). The mean operative time was 181 ± 39 min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n = 2) and vaginal (n = 2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7 ± 2.3 d (3–11). The bladder catheter was removed after a mean time of 10 ± 8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1 ± 8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

Conclusions

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.     

Metachronous benign ovarian tumors are not uncommon in children

Purpose

To evaluate the risk for metachronous ovarian tumor in pediatric patients with mature ovarian teratoma.

Methods

During 1981–2011, 22 children underwent oophorectomy for mature teratoma at the median age of 11.4 (range 1.5–15.3) years. The patients were followed-up in median 4.4 (range 0.5–25.5) years.

Results

None of the patients had synchronous bilateral tumor at the time of primary operation, but during follow-up five patients (23%) got metachronous contralateral ovarian tumor. The contralateral tumor was observed in median 3.6 (range 1–8.8) years after the primary operation. According to Kaplan–Meier analysis the risk for contralateral tumor was 14% ± 8% (SE) within five years and 66% ± 26% (SE) within 10 years. In this series, the contralateral tumor was operated by ovary preserving surgery. Three of the metachronous tumors were mature teratomas and two were seromucinous infantile cystadenomas. One patient had a second teratoma recurrence 14 years after the first recurrence.

Conclusions

More than one fifth of the children with ovarian mature teratoma get metachronous benign tumor to the contralateral ovary. Therefore a yearly ultrasound follow-up is needed for these patients up to potential pregnancy to enable early diagnosis, ovary preserving surgery and maintenance of fertility in the case of metachronous tumor.     

Management of epididymal cysts in childhood

Background

A retrospective review was carried out to evaluate the clinical presentation of children with epididymal cysts (EC) and outcome of management at our institution.

Methods

There were 49 patients with EC in this series. The diagnosis of EC was made by physical examination and confirmed by ultrasound (US).

Results

The average age at presentation was 10.7 years (2 months–16 years). Scrotal mass (n: 22) and pain (n: 21) were the most frequent symptoms. Seven patients were lost to follow-up. The cysts were solitary in 32 patients and multiple in 10 patients. The mean value of cysts was 6.7 mm (2–20 mm). The cyst localisations were 22 in left, 16 in right, and bilateral in 4 patients. Complete involution of cysts was detected in 14 children. The average involution time was 11.2 months (1–37 months). In 20 cases, a decrease in cyst size was found. Cyst excision was performed in 8 patients with persistent scrotal pain or no cyst involution observed during follow-up.

Conclusion

Conservative management of epididymal cysts is practical. However, surgical excision is recommended in patients with intractable scrotal pain or if the cyst size does not seem to involute.     

Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up

Background

Robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer.

Objective

We report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit.

Design, setting and participants

From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases.

Surgical procedure

A six port transperitoneal approach using a 4-arm da Vinci^® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up.

Measurements

Perioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ≥0.2 ng/mL) is used as a surrogate for cancer control.

Results and limitations

The mean age ± standard deviation (SD) was 60.2 ± 6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3–9.6) ng/mL. The mean operating time ± SD was 186 ± 49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively.The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR = 15–30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ≥21) who underwent nerve-sparing RALP, 62% were potent at 12 months.

Conclusions

The safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes.     

Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: A case series

Introduction

Diabetics, smokers, patients with open fractures and drug addicts have shown to be at increased risk of having wound complications with traditional calcaneus fixation. The purpose of the study is to examine if high-risk patients with intra-articular calcaneus fractures can be managed safely using percutaneous reduction and fixation by examining a consecutive series of patients treated by the senior author.

Methods

The treatment group consisted of the senior author's first 17 percutaneously treated calcaneus fractures in high-risk patients. Risk factors included: open fracture, smoking, diabetes and cocaine, alcohol and solvent abuse. Reduction techniques included temporary external fixation, inflatable bone tamps, and arthroscopic assisted reduction manoeuvres. Fixation was accomplished with cannulated 4.5 mm screws. Patients were followed up for 3 months minimum to look for wound complications and subsidence.

Results

Surgery was performed within 15 days from injury (average 6.7 days). Risk factors included: open fracture 1, smoking 16, diabetes 2, and substance abuse 9. Sanders’ classification described: six type 2, nine type 3 and two type 4. Bohlers’ angle increased from an average of −1.5° (range −37° to +30) to 25.8° (range 7–36°). There were no wound issues or infections with the calcaneal fixation. Reduction was deemed excellent or good in 14, fair in 2 and poor in 1. Loss of Bohlers’ angle of >4° occurred in four cases; in three of these, the patients were non-compliant with weight bearing.

Conclusion

High-risk patients with intra-articular calcaneus fractures that meet the criteria for surgical management can be managed with percutaneous surgical techniques with low risk of wound complications.     

Robotic Intracorporeal Orthotopic Ileal Neobladder: Replicating Open Surgical Principles

Background

Robotic radical cystectomy (RC) for cancer is beginning to gain wider acceptance. Yet, the concomitant urinary diversion is typically performed extracorporeally at most centers, primarily because intracorporeal diversion is perceived as technically complex and arduous. Previous reports on robotic, intracorporeal, orthotopic neobladder may not have fully replicated established open principles of reservoir configuration, leading to concerns about long-term functional outcomes.

Objective

To illustrate step-by-step our technique for robotic, intracorporeal, orthotopic, ileal neobladder, urinary diversion with strict adherence to open surgical tenets.

Design, setting, and participants

From July 2010 to May 2012, 24 patients underwent robotic intracorporeal neobladder at a single tertiary cancer center. This report presents data on patients with a minimum of 3-mo follow-up (n = 8).

Surgical procedure

We performed robotic RC, extended lymphadenectomy to the inferior mesenteric artery, and complete intracorporeal diversion. Our surgical technique is demonstrated in the accompanying video.

Outcome measurements and statistical analysis

Baseline demographics, pathology data, 90-d complications, and functional outcomes were assessed and compared with patients undergoing intracorporeal ileal conduit diversion (n = 7).

Results and limitations

Robotic intracorporeal urinary diversion was successfully performed in 15 patients (neobladder: 8 patients, ileal conduit: 7 patients) with a minimum 90-d follow-up. Median age and body mass index were 68 yr and 27 kg/m², respectively. In the neobladder cohort, median estimated blood loss was 225 ml (range: 100–700 ml), median time to regular diet was 5 d (range: 4–10 d), median hospital stay was 8 d (range: 5–27 d), and 30- and 90-d complications were Clavien grade 1–2 (n = 5 and 0), Clavien grade 3–5 (n = 2 and 1), respectively. This study is limited by small sample size and short follow-up period.

Conclusions

An intracorporeal technique of robot-assisted orthotopic neobladder and ileal conduit is presented, wherein established open principles are diligently preserved. This step-wise approach is demonstrated to help shorten the learning curve of other surgeons contemplating robotic intracorporeal urinary diversion.     

A Review of the Current Status of Laparoscopic and Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse

Context

Abdominal sacrocolpopexy (ASC) represents the superior treatment for apical pelvic organ prolapse (POP) but is associated with increased length of stay, analgesic requirement, and cost compared with transvaginal procedures. Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) may offer shorter postoperative recovery while maintaining equivalent rates of cure.

Objective

This review evaluates the literature on LSC and RSC for clinical outcomes and complications.

Evidence acquisition

A PubMed search of the available literature from 1966 to 2013 on LSC and RSC with a follow-up of at least 12 mo was performed. A total of 256 articles were screened, 69 articles selected, and outcomes from 26 presented. A review, not meta-analysis, was conducted due to the quality of the articles.

Evidence synthesis

LSC has become a mature technique with results from 11 patient series encompassing 1221 patients with a mean follow-up of 26 mo. Mean operative time was 124 min (range: 55–185) with a 3% (range: 0–11%) conversion rate. Objective cure was achieved in 91% of patients, with similar satisfaction rates (92%). Six patient series encompassing 363 patients treated with RSC with a mean follow-up of 28 mo have been reported. Mean operative time was 202 min (range: 161–288) with a 1% (range: 0–4%) conversion rate. Objective cure rate was 94%, with a 95% subjective success rate. Overall, early outcomes and complication rates for both LSC and RSC appeared comparable with open ASC.

Conclusions

LSC and RSC provide excellent short- to medium-term reconstructive outcomes for patients with POP. RSC is more expensive than LSC. Further studies are required to better understand the clinical performance of RSC versus LSC and confirm long-term efficacy.

Patient summary

Laparoscopic and robot-assisted sacrocolpopexy represent attractive minimally invasive alternatives to abdominal sacrocolpopexy. They may offer reduced patient morbidity but are associated with higher costs.     

Using the parents' video camera for the follow-up of children who have undergone hypospadias surgery decreases hospital anxiety of children

Purpose

We investigated the benefits of using the parents' video camera records for the follow-up of children who had undergone hypospadias surgery in terms of reducing fear and hospital anxiety of the children and the time spent in the waiting room.

Methods

This prospective study was performed on children with proximal hypospadias. The patients were called for the follow-up appointment on the 7th postoperative day and were divided into 3 groups. The first group was the control group where parents were not given any follow-up visit direction. The parents of the second group were told to have their child drink enough fluids and come with a full bladder, while the third group of parents recorded their child's micturition using a video camera. The fear and anxiety of children at the postoperative visit were evaluated and recorded using a scoring system between 0 and 4 using the Children's Fear Scale (CFS) brochure. The time elapsed from the arrival of the parents in the outpatient clinic to their departure was also recorded for comparison of the total time spent during the follow-up visit among the groups.

Results

Thirty boys who underwent hypospadias repair were enrolled in this study. The median CFS scores at the postoperative follow-up visit were 2.99 ± 0.99 (range: 1–4) in the first group, 2.90 ± 0.87 (range: 1–4) in the second group, and 0.00 (range 0–0) in the third group. The median total time spent during the follow-up visit in the 3 groups was 61.50 ± 17.08 (range 35–88), 18.1 ± 13.01 (range 4–45), and 4.0 ± 0.81 (3–5) minutes, respectively. Both CFS and total time spent were significantly lower in the third group (p < 0.01).

Conclusion

Imaging of micturition at home by using a video camera for outpatient visits following hypospadias surgery will decrease the fear and anxiety of children and the time that the family spends at the hospital.