Percutaneous nephrolithotomy of a staghorn stone in thoracic ectopic kidney

Congenital thoracic ectopic kidney is a very rare developmental anomaly and the rarest form of all ectopic kidneys. It is usually asymptomatic and discovered incidentally on routine chest radiography. Herein we reported the first case of staghorn stone in a thoracic kidney managed successfully by percutaneous nephrolithotomy.     

Complex urethral disruptions: In pursuit of a successful reconstruction

OBJECTIVES: We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions. METHODS: The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics. RESULTS: End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%. CONCLUSION: Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.     

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time. Presented at the British Association of Plastic Surgeons Summer Scientific Meeting, Sheffield, UK (12 July 2006).     

Intrathecal fentanyl prolongs sensory bupivacaine spinal block

The purpose of investigation was to study the effect of intrathecal fentanyl on the onset and duration of hyperbaric bupivacaine-induced spinal block in adult male patients. Fortythree patients undergoing lower extremity or genitourinary surgery were enrolled to receive either 13.5 mg hyperbaric bupivacaine 0.75% + 0.5 ml CSF it, (Group I) or 13.5 mg hyperbaric bupivacaine 0.75% + 25 μg fentanyl it, (Group II) according to a randomized assessor-blind protocol. The onset and duration of sensory block were assessed by pinching the skin with forceps in the midclavicular line bilaterally every two minutes for first twenty minutes and then every five to ten minutes. Similarly, the onset and duration of motor block were assessed and graded at the same time intervals using the criteria described by Bromage. The time required for two sensory segment regression and sensory regression to L₁ dermatome was 74 ± 18 and 110 ± 33 min vs 93 ± 22 and 141 ± 37 min in Groups I and II, respectively (P < 0.05). Intrathecal fentanyl did not enhance the onset of sensory or motor block, or prolong the duration of bupivacaine-induced motor spinal block. Fewer patients demanded pain relief in the fentanyl-treated group than in the control group in the early postoperative period (19% vs 59%; P < 0.05). Episodes of hypotension were more frequent in the fentanyl-treated group than in the control group (43% vs 14%; P < 0.05). We conclude that fentanyl, 25 μg it, prolonged the duration of bupivacaine-induced sensory block (sensory regression to L₁ dermatone) by 28% and reduced the analgesic requirement in the early postoperative period following bupivacaine spinal block.     

Management of progressive exophthalmos

The present study reveals our experience in the medical management of 30 cases of progressive/malignant exophthalmos, employing costicosteroid, b-blocker, diuretic and a preparation containing proteolytic enzymes. There was encouraging improvement in terms of symptoms, proptosis and optic nerve compression, while reduction of ophthalmoplegia was not so satisfactory. However, none of the patients needed decompression surgery.     

Spontaneous gallbladder perforation—An unusual presentation of carcinoma of the pancreas

A 50 year old man with a two month history of upper abdominal pain and a one month history of anorexia and weight loss, presented with icterus and evidence of peritonitis. Laparotomy revealed biliary peritonitis which had been caused by a rupture of the fundus of the gallbladder. The common bile duct was dilated and there was a large growth in the head of the pancreas with multiple hepatic metastases. A cholecysto-jejunostomy and gastrojejunostomy were done and the patient had an uneventful recovery.