The Graf/Biggs Flap to Increase Upper Pole Projection in Breast Reductions with Free Nipple Grafts

Background  

Macromastia necessitating breast reduction with free nipple grafts often results in a breast shape that lacks upper pole projection. This study aimed to describe and review the experience with use of the Graf/Biggs flap to improve upper pole fullness in patients requiring breast reductions with free nipple grafts.     

Outcome study of upper pole heminephroureterectomy in children

Objective  

We assessed the role and long-term outcome of upper pole heminephroureterectomy in the treatments of non-functioning upper renal moieties in children with duplex kidneys.     

Upper-pole puncture in percutaneous nephrolithotomy: a retrospective review of treatment safety and efficacy

OBJECTIVE

To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi.

PATIENTS AND METHODS

Over a 12‐year period, 66 patients had either an upper‐pole puncture alone or combined with middle‐ or lower‐pole puncture during PCNL for renal calculi. All punctures were made by an experienced uroradiologist and were either supra‐ or subcostal. We retrospectively reviewed all case notes and radiographs to determine stone‐clearance rates and complications associated with the site and number of punctures.

RESULTS

There was an overall stone‐free rate of 78% with upper‐pole puncture alone or combined with middle‐ or lower‐pole puncture. There was a 3% thoracic complication rate with upper pole punctures, and an overall complication rate of 30% for both thoracic and non‐thoracic complications.

CONCLUSION

Upper‐pole puncture in PCNL is associated with minimum morbidity if done by an experienced urologist or radiologist. The stone‐free rate appears to be more dependent on stone size and complexity than the site of puncture.     

Retrograde Thyroidectomy: A Technique for Visualization and Preservation of the External Branch of Superior Laryngeal Nerve

INTRODUCTION

The external branch of the superior laryngeal nerve (EBSLN) should be identified during thyroidectomy to prevent injury and post-operative voice change. Identification is rendered difficult during a standard thyroidectomy where there is a large gland with upper pole enlargement. We describe the retrograde thyroidectomy technique to facilitate nerve preservation.

PRESENTATION OF CASE

A retrograde thyroidectomy was performed in a 53-year old woman with a difficult goiter. Operative steps are described.

DISCUSSION

This technique allows the upper pole to be completely mobilized caudally providing unparalleled visualization of the upper pole vascular pedicle, thereby preserving the EBSLN.

CONCLUSION

There is better visualization of the superior thyroid pedicle and the EBSLN with retrograde thyroidectomy, potentially reducing the incidence of EBSLN injury during a difficult thyroidectomy.     

Breast Augmentation and Mastopexy Using a Pectoral Muscle Loop

Background  

Augmentation mastopexy has historically challenged the creativity of plastic surgeons. Recurrent breast ptosis is the main cause for revision after such a primary operation. Avoiding the need for reoperation and achieving long-term projection and upper pole fullness have been the main focus for the work of many authors. In this study, a new approach for a stable and lasting breast shape based on the use of the pectoral muscle was conceived.     

Pelvi-ureteric junction obstruction in duplex kidneys

OBJECTIVE

To report our experience of 11 children with pelvi‐ureteric junction obstruction (PUJO) in a duplex kidney and to review previous reports.

PATIENTS AND METHODS

From 1995 to 2005 the second author (G.H.H.S.) performed 145 pyeloplasties in single‐system kidneys and in 11 children with PUJO in a duplex kidney. Upper and lower pole obstructions were found in both complete and incomplete duplicated systems. Investigations included renal ultrasonography, renal scintigraphy, micturating cystography, cystoscopy and retrograde pyelography. Ten patients had surgery (eight dismembered pyeloplasties, one upper‐pole heminephrectomy, one pyelo‐ureterostomy).

RESULTS

Three children had obstruction of the upper moiety and eight had obstruction of the lower moiety. Upper and lower pole obstructions were found in both complete and incomplete duplicated systems.

CONCLUSION

Upper‐pole obstruction in a duplex kidney is rare; the present series suggests that it is more common than previously reported.     

Laparoscopic reconstructive options for obstruction in children with duplex renal anomalies

OBJECTIVE

To present our initial experience of laparoscopic reconstructive surgery in children with upper urinary tract obstruction associated with duplex anomalies, as although there is much information on ablative procedures such as laparoscopic heminephrectomy, there is little available about minimally invasive reconstructive options for duplex renal anomalies in children.

PATIENTS AND METHODS

We retrospectively reviewed four consecutive patients (aged 6–11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at our institution. The port placement and surgical exposure were analogous to that for transperitoneal laparoscopic pyeloplasty. A JJ stent was placed retrogradely into the ureter immediately before each procedure. The procedures performed were pyelo‐ureterostomy for incomplete duplication and lower pole pelvi‐ureteric junction (PUJ) obstruction, lower pole pyeloplasty for lower pole PUJ obstruction and complete duplication, and ipsilateral uretero‐ureterostomy and distal ureterectomy for an obstructed, ectopic upper pole. Foley catheters were left indwelling for 36–48 h and stents were removed at 4–6 weeks. Postoperative imaging included either ultrasonography or intravenous urography.

RESULTS

Three children presented with intermittent flank pain due to lower pole PUJ obstruction. The other child presented with pyonephrosis and purulent drainage from her vagina due to an ectopic ureter associated with a functioning upper pole segment. All procedures were successfully completed. The only complication was in the first patient (pyelo‐ureterostomy) who had transient urinary extravasation that resolved with bladder decompression for 10 days. With a follow‐up of 6–18 months, all had resolution of symptoms with improvement in radiographic variables.

CONCLUSIONS

This series shows that children with duplex anomalies and obstruction can undergo successful reconstruction using techniques learned with laparoscopic pyeloplasty.     

Subpectoral-Subfascial Breast Augmentation for Thin-Skinned Patients

Background  

Among thin patients, upper pole skin of less than 2 cm on a pinch test is an indication for submuscular implant placement. However, rippling, palpability, and visibility of the implant are frequently observed in the lower and lateral aspects of the breast due to the lack of muscle coverage in the area. To overcome these problems, a subpectoral-subfascial breast augmentation was performed including subfascial dissection of the rectus abdominis, external abdominal oblique muscle, and serratus anterior muscle as one sheet to cover the inferolateral aspect of the implant.     

Extracorporal shock wave lithotripsy in the management of stones in children with oxalosis—still the first choice?

Background

Primary hyperoxaluria (PH) is a recognised cause of nephrolithiasis. The aim of this study was to evaluate the success of extracorporal shock wave lithotripsy (ESWL) in treating nephrolithiasis in children with PH.

Methods

This was a retrospective review of patient characteristics, treatments and outcomes of 36 children with oxalate stones due to PH.

Results

A total of 52 stones were formed in 28 patients, of which 23 stones were treated with ESWL. Of these 23 stones, ten improved and 13 did not; nine were located in the upper pole, nine in the lower pole and four and one in the pelvic and ureteric areas, respectively. All pelvic and ureteric stones improved, while 66.7 % of upper pole stones and 89.9 % of lower pole stones did not; 20 % of PH type 1 stones improved compared to 47 % of PH type 2 stones. The mean pre- and post-eGFR in stone-improvers was 98.82 and 104.7 ml/min/1.73 m², respectively; in the non-improvers, these values were 100.75 and 95.68 ml/min/1.73 m², respectively. Mean pre-ESWL stone size in the improved and non-improved groups was 7.3 mm and 8.5 mm respectively.

Conclusions

Based on our results, ESWL is not the ideal method of stone therapy for patients with PH. ESWL was more effective in treating pelvic and ureteric stones, with upper pole stone response being better than lower pole response. PH2 patients were more than twice as likely to respond to ESWL treatment. Stone size and prior preventive treatment did not affect outcome. eGFR was not affected by ESWL.     

Non-vascularized bone graft with Herbert-type screw fixation for proximal pole scaphoid nonunion

Background  

Since proximal pole fractures of the scaphoid are frequently overlooked, the poor vascularity in the proximal pole fragment often leads to nonunion. Vascularized bone grafts have been recently tested in cases with scaphoid proximal pole nonunion, but the indication for this treatment has not been well established. Alternatively, we have been treating such patients with a non-vascularized iliac bone graft and Herbert-type screw fixation with considerable success. The purpose of this investigation is to evaluate these cases retrospectively and clarify the surgical efficacy of our procedure.     

The association of adult kidney size with childhood vesicoureteral reflux

Background

We used ultrasound to measure kidney volumes in adults with a history of childhood vesicoureteral reflux (VUR) and assessed whether total renal volume, small kidney size or the thickness of the upper pole correlated with renal function or hypertension.

Methods

The kidneys of 123 adults were studied by ultrasound, calculating their volumes using an ellipsoid formula normalised to body surface area (Vol_N). The thickness of the upper pole parenchyma and the number of small kidneys (<80% of normal volume) were recorded. Blood pressure measurements and laboratory tests were also performed.

Results

Kidneys with a history of VUR were 12% smaller than those without known VUR (p?<?0.05), and those with prior dilating VUR were 16% smaller than those with non-dilating VUR (p?<?0.05). There was a moderate correlation (r?=?0.42, p?<?0.05) between total Vol_N and GFR values in the total patient series. Thirteen percent of the patients had a moderate decrease in kidney function. The occurrence of hypertension and proteinuria was not affected by either kidney size or a thin upper pole.

Conclusions

Total Vol_N in ultrasound in early adulthood could probably predict possible renal deterioration in later life. The occurrence of one small kidney was a common finding and seemed not to affect the prevalence of proteinuria or hypertension.     

Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy – the controversy continues

Background  

To determine factors influencing the clearance of fragments after extra-corporeal shock wave lithotripsy (ESWL) for lower pole calyceal (LPC) stones.     

Rigid and flexible endoscopic rendezvous in spatium peritonealis may be an effective tactic for laparoscopic megasplenectomy: significant implications for pure natural orifice translumenal endoscopic surgery

Background

We recently experienced 10 patients with cirrhosis who underwent laparoscopic splenectomy. A portion of these patients underwent dissection with a flexible endoscope in the peritoneal cavity. This pilot study mainly focused on the technical aspects and immediate results.

Methods

From November 2009 to September 2010, 10 patients with cirrhosis and hypersplenism were entered into this pilot study. They were indicated to undergo laparoscopic splenectomy to treat portal hypertension and to facilitate initiation and completion of either interferon therapy for liver cirrhosis or anticancer therapy for hepatocellular carcinoma. To dissect the upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen, a flexible single-channel endoscope was introduced into the peritoneal cavity simultaneously with the use of a rigid laparoscope. Dissection with the flexible endoscope in the peritoneal cavity was performed using an insulation-tipped electrosurgical knife through the channel of the flexible endoscope.

Results

The flexible endoscope offered a magnified operative view, a water-jet lens cleaner, and a powerful lavage and suction capability. The upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen were easily seen, and dissection of these critical regions was smoothly conducted with articulation of the tip of the flexible endoscope, even in patients with splenomegaly. No patient experienced major intraoperative complications or required conversion to open surgery.

Conclusions

Dissection with a flexible endoscope in the peritoneal cavity may be an effective tactic for laparoscopic megasplenectomy, and significant implications for pure natural orifice translumenal endoscopic surgery have been raised. Although future randomized controlled prospective studies are needed to confirm these findings, surgeons might find this to be a typical example of an appropriate strategy for high-risk patients.     

The Identification,Preservation and Classification of the External Branch of the Superior Laryngeal Nerve in Thyroidectomy

Background

Avoiding injury to the external branch of the superior laryngeal nerve is one of the major challenges during thyroid operation. The aim of this study was to propose a practical classification of the external branch of the superior laryngeal nerve.

Methods

A retrospective study of total thyroidectomy was performed. Totally 240 patients were included, with 480 external branches of the superior laryngeal nerves explored by intraoperative neuromonitoring. The classification of the external branch of the superior laryngeal nerve was determined by the distance between the upper edge of the superior thyroid pole and the lowest point of the nerve when the thyroid lobe was retracted in the lateral and inferior direction. Multinomial logistic regression analysis was run to predict the type of the nerve from several variables.

Results

The identification rate of the external branch of the superior laryngeal nerve was 98.54% (473 of 480 nerves). Higher ratio of longitudinal size of the thyroid lobe to ipsilateral neck length increased the likelihood of that both the type 2 and 3 nerve with respect to type 1 nerve, with OR 2.72, 95% CI = 1.21–6.12 and OR 5.30, 95% CI = 2.09–13.44, respectively. (1a) The nerve whose lowest point (entry into the muscle) was located more than 1 cm above the horizontal plane passing the upper border of superior thyroid pole. (1b) The nerve whose lowest point (the point right above the superior thyroid pole) was located more than 1 cm above the plane. (2a) The nerve whose lowest point (entry into the muscle) was located within 1 cm above the plane. (2b) The nerve whose lowest point (the point right above the superior thyroid pole) was located within 1 cm above the plane. (3a) The nerve whose lowest point (entry into the muscle) was located below the plane. (3b) The nerve whose lowest point (the point right below the superior thyroid pole) was located anterior to the gland. (3c) The nerve whose lowest point (the point right below the superior thyroid pole) was located posterior to the gland.

Conclusions

Identification rate of the external branch of the superior laryngeal nerve by intraoperative neuromonitoring was significantly high. Understanding the new practical classification of the nerve allows for better identification and function preservation of this nerve during thyroidectomy.

     

Epstein-Barr virus associated primary intracranial leiomyoma in organ transplant recipient: case report and review of the literature

Introduction  

A 45 year old female renal transplant recipient presented with headaches of 3 months duration. Clinical and radiological evaluation revealed an approximately 4x4cm rounded, enhancing mass at the left temporal pole. At surgery, the mass had dural attachment and clinically, radiographically, and macroscopically resembled a meningioma. Histopathological analysis revealed a leiomyoma. Epstein-Barr virus (EBV) DNA was demonstrated within the tumour cell nuclei by the in situ hybridisation technique.     

NEPHRON SPARING MANAGEMENT OF FRALEY''S SYNDROME WITH A PYELOPYELOSTOMY

Purpose

We describe a new technique for nephron sparing management of functionally significant vascular compression of the upper pole infundibulocaliceal system (Fraley's syndrome).

Materials and Methods

Two patients evaluated for debilitating, narcotic dependent flank pain had significant upper pole infundibulocaliceal obstruction resulting from aberrant major arterial branches entering the hilum dorsally. Reconstructive surgery consisted of dismembered pyelopyelostomy with transposition of the crossing vessels in both patients.

Results

Pain relief was immediate and complete in both patients. Followup radiographic evaluation at 1 and 12 months, respectively, has also documented resolution of the obstruction.

Conclusions

Vascular compression causing obstruction of the superior infundibulum can cause debilitating pain. Pathophysiologically operative intervention can be nephron sparing and gratifying for the surgeon and the patient.     

Upper cervical spine injuries: age-specific clinical features

Background  

There are few reports on the age-specific clinical features of upper cervical spine injury. To identify these age-specific changes, we reviewed 103 patients with upper cervical spine injury.     

Ipsilateral Pyeloureterostomy for Managing Lower Pole Reflux with Associated Ureteropelvic Junction Obstruction in Duplex Systems

Purpose

In duplex renal systems with a normal upper pole collecting system, and a lower pole collecting system with reflux and ureteropelvic junction obstruction or a kink at the ureteropelvic junction (that is reflux with trapping), treatment must address reflux and obstruction. We reviewed the results of ipsilateral pyeloureterostomy as a single corrective procedure.

Materials and Methods

We retrospectively reviewed our experience with 10 children who had complete ureteral duplication with lower pole reflux (grades III to V) and associated lower pole ureteropelvic junction obstruction or a ureteral kink with trapping. All patients were treated with ipsilateral end-to-side pyeloureterostomy. Followup ranged from 1 to 14 years.

Results

All patients had a good postoperative result, there have been no immediate or long-term complications and no subsequent surgical procedure was needed. All patients had continued lower pole renal growth with good function, 9 had resolution or a marked decrease in pelvicaliceal dilatation and none had evidence of obstruction.

Conclusions

Ipsilateral end-to-side pyeloureterostomy for treating reflux into the lower moiety of a duplicated collecting system with associated ureteropelvic junction obstruction or a kink appears to be a single, safe corrective procedure that simultaneously manages vesicoureteral reflux and relieves the proximal obstructive process.     

Percutaneous Ureteral Elevation in Laparoendoscopic Single-Site Radical Nephrectomy

Background and Objectives:

To describe our technique of suture-assisted ureteral retraction during Laparoendoscopic Single-Site (LESS) radical nephrectomy.

Materials and Methods:

A healthy, 39-year-old woman with an incidental 5-cm enhancing left renal mass elected to undergo radical nephrectomy. A 2-cm skin incision was made in the left upper quadrant of the abdomen, and a Covidien SILS port was introduced using standard Hasson techniques. Straight and angled laparoscopic instruments were used to mobilize the kidney outside of Gerota''s fascia. To place the renal vessels on stretch and facilitate hilar dissection, the ureter and lower pole attachments were encircled with a 0-Vicryl suture inserted percutaneously via a disposable fascial closure device. The kidney was bagged and removed intact.

Results:

The procedure was performed without complication with a total operative time of 265 minutes. EBL was minimal at 25mL. The patient was discharged home on postoperative day 1, and final pathology revealed stage pT1b chromophobe renal cell carcinoma with negative surgical margins.

Conclusion:

LESS radical nephrectomy is feasible in select patients. Suture-assisted retraction of the ureter and lower pole attachments using a fascial closure device facilitates safe dissection and control of the renal hilum.     

Aesthetical outcome after breast reconstruction using deep inferior epigastric perforator flap: Personal techniques

Background:

Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons.

Materials and Methods:

The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. Results: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases.

Conclusion:

The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.KEY WORDS: Aesthetic refinements, breast reconstruction, deep inferior epigastric perforator flap