NEEDLE RENAL LIFTING TECHNIQUE IN MANAGEMENT OF COMPLICATED PROXIMAL URETERAL LITHOTRIPSY: A CASE REPORT

Objective: To described a needle renal lifting technique using an 18-gauge needle to adjunct ureterorenoscopy (URS) in the management of complicated proximal ureteral stones. Case(s) Presentation: A 46 years old man presented with right flank pain for 1 month. This patient was diagnosed with ureteral stone and ureteral kinking that prohibits access to the proximal side of the ureter. Due to difficult access to the proximal ureter, we perform a needle renal lifting technique which is initialized by puncturing the middle renal calyx with 18-gauge needle. Then, the proximal end of the needle was pushed to the caudal direction to move the kidney to the cephalic direction and straighten the kinked ureter. After that procedure, the URS sheat can easily enter the proximal ureter to the stone site. Discussion: The success rate of this procedure is based on the operator skills to access the calyx and perform URS simultaneously. Like a previous technique, needle renal lifting is effective only when the kidney is mobile. Conclusion: The needle renal lifting technique can be used to adjunct URS in the management of complicated ureteral stones which prohibited access to the proximal ureter.

Proximal Side Optimization: A Modification of the Double Kissing Crush Technique

Coronary bifurcations with significant lesions >10 mm in the side branch (SB) are likely to require two-stent treatment techniques. To date, double kissing Crush (DK-Crush) stenting has demonstrated higher rates of final kissing balloon inflation and better clinical outcomes. The technical iterations that lead to optimal clinical outcomes have been attributed to the first kissing balloon that repairs the distorted proximal segment and fully expands the orifice of the side stent. One potential caution, which relates to all Crush techniques, is the possibility of the guidewire crossing in an inappropriate position toward the Crushed SB stent. When this occurs, the SB stent may be further Crushed, leaving the ostium uncovered, which potentially negates the benefit of the Crush technique. In our experience, proximal side optimization (PSO) during DK-Crush stenting ensures stent size ‘accommodation’ to the larger vessel diameter in the proximal segment and better strut apposition to the wall, which is particularly important in the ostial segment. The benefits of this additional modification of the established DK-Crush technique are reduction or elimination of the risk of SB stent distortion, increase of the space of optimal wiring, and avoidance of guidewire advancement under the stent struts, even in unfavorable anatomies with extreme angulation. The author describes a step-by-step approach of a proposed PSO technique, which is easy to perform without any additional procedural time or costs.

Enhancement of tendon-bone interface healing and graft maturation with cylindrical Titanium-Web (TW) in a miniature swine anterior cruciate ligament reconstruction model: Histological and collagen-based analysis

Background: Tendon-bone interface healing and ligamentization of the graft in anterior cruciate ligament (ACL) reconstruction with autografts are important factors affecting treatment outcome. This study aimed to investigate the effectiveness of a cylindrical titanium-web (TW) in tendon-bone interface healing and graft maturation in ACL reconstruction. Methods: Fourteen mature female CLAWN miniature swine underwent bilateral ACL reconstructions with patellar tendon (PT) autografts. In one limb, the TW/tendon complex was placed into the proximal side of the tibial tunnel. Only the graft was transplanted into the tunnel in the control limb. The proximal side of the graft was sutured into the stump of the native ACL and the distal end was stapled to the tibia. The animals were euthanized at 4 and 15 weeks postoperatively, for histological and biochemical analyses. Results: Microscopic images in TW limbs showed that ingrowth of tendon-like tissue and mineralized bone tissue into the TW connected the bone and the tendon directly. In contrast, fibrous tissue intervened between the bone and tendon in the control limbs. The total amount of collagen cross-links (which defines the strength of collagen fibers) and the maturation of collagen cross-links in TW tendons were significantly higher (p<0.05) than those of control limbs. There was no significant difference in the ratio of dihydroxy-lysinonorleucine to hydroxy-lysinonorleucine (an indicator of tissue specific collagen maturation) between TW tendons and that of the native PT. Conclusions: TW promoted the maturation and formation of collagen cross-links in the grafted tendon while maintaining the cross-links pattern of native tendon collagen, and enabled direct binding of tendon to bone.

Enhancement of tendon-bone interface healing and graft maturation with cylindrical Titanium-Web (TW) in a miniature swine anterior cruciate ligament reconstruction model: Histological and collagen-based analysis

Background: Tendon-bone interface healing and ligamentization of the graft in anterior cruciate ligament (ACL) reconstruction with autografts are important factors affecting treatment outcome. This study aimed to investigate the effectiveness of a cylindrical titanium-web (TW) in tendon-bone interface healing and graft maturation in ACL reconstruction. Methods: Fourteen mature female CLAWN miniature swine underwent bilateral ACL reconstructions with patellar tendon (PT) autografts. In one limb, the TW/tendon complex was placed into the proximal side of the tibial tunnel. Only the graft was transplanted into the tunnel in the control limb. The proximal side of the graft was sutured into the stump of the native ACL and the distal end was stapled to the tibia. The animals were euthanized at 4 and 15 weeks postoperatively, for histological and biochemical analyses. Results: Microscopic images in TW limbs showed that ingrowth of tendon-like tissue and mineralized bone tissue into the TW connected the bone and the tendon directly. In contrast, fibrous tissue intervened between the bone and tendon in the control limbs. The total amount of collagen cross-links (which defines the strength of collagen fibers) and the maturation of collagen cross-links in TW tendons were significantly higher (p<0.05) than those of control limbs. There was no significant difference in the ratio of dihydroxy-lysinonorleucine to hydroxy-lysinonorleucine (an indicator of tissue specific collagen maturation) between TW tendons and that of the native PT. Conclusions: TW promoted the maturation and formation of collagen cross-links in the grafted tendon while maintaining the cross-link pattern of native tendon collagen, and enabled direct binding of tendon to bone.

A Case of Laterally Spreading Tumor of the Rectum Treated by Endoscope-Assisted Transanal Tumor Resection

Background: Curability and function should be considered in resection of a rectal lateral spreading tumor (LST). Methods: We performed endoscopic transanal resection for a rectal LST extending to the pectinate line to preserve anal function and avoid a colostomy in 1 case and describe our procedure below. An 80-year-old man with a group 5 adenocarcinoma tub1/2 and no metastasis was considered for transanal resection because of his refusal of a colostomy and for staging and preservation of anal function. A strategy involving endoscopic submucosal dissection for mucosal cutting at the proximal side and for submucosal dissection of the maximum area at the anal side of the tumor was chosen, considering the tumor size. With the patient in a jackknife position, the tumor was marked circumferentially with coagulation dots, after which MucoUp with bosmin was injected into the submucosa at the proximal side. Mucosal and submucosal dissection was performed using DualKnife to remove the largest possible area toward the anal side. Transanal resection was performed under direct vision using an anal retractor, wherein the mucosa was cut circumferentially by extending the existing resection line along with removal of the submucosa. Results: En bloc resection with clear margins was achieved. Postoperatively, retroperitoneal emphysema was observed on a computed tomography scan, which resolved after 1 week of fasting. The patient was discharged 20 days postoperatively. Neither recurrence nor metastasis has been observed 1 year postoperatively. Conclusions: Our procedure enabled successful resection of a rectal LST with negative margins and preservation of anal function.

Enhancement of tendon-bone interface healing and graft maturation with cylindrical Titanium-Web (TW) in a miniature swine anterior cruciate ligament reconstruction model: Histological and collagen-based analysis

Background: Tendon-bone interface healing and ligamentization of the graft in anterior cruciate ligament (ACL) reconstruction with autografts are important factors affecting treatment outcome. This study aimed to investigate the effectiveness of a cylindrical titanium-web (TW) in tendon-bone interface healing and graft maturation in ACL reconstruction.Methods: Fourteen mature female CLAWN miniature swine underwent bilateral ACL reconstructions with patellar tendon (PT) autografts. In one limb, the TW/tendon complex was placed into the proximal side of the tibial tunnel. Only the graft was transplanted into the tunnel in the control limb. The proximal side of the graft was sutured into the stump of the native ACL and the distal end was stapled to the tibia. The animals were euthanized at 4 and 15 weeks postoperatively, for histological and biochemical analyses. Results: Microscopic images in TW limbs showed that ingrowth of tendon-like tissue and mineralized bone tissue into the TW connected the bone and the tendon directly. In contrast, fibrous tissue intervened between the bone and tendon in the control limbs. The total amount of collagen cross-links (which defines the strength of collagen fibers) and the maturation of collagen cross-links in TW tendons were significantly higher (p<0.05) than those of control limbs. There was no significant difference in the ratio of dihydroxy-lysinonorleucine to hydroxy-lysinonorleucine (an indicator of tissue specific collagen maturation) between TW tendons and that of the native PT. Conclusions: TW promoted the maturation and formation of collagen cross-links in the grafted tendon while maintaining the cross-link pattern of native tendon collagen, and enabled direct binding of tendon to bone.

Molecular Basis for Natural Vegetative Propagation via Regeneration in North American Lake Cress, Rorippa aquatica (Brassicaceae)

Some plant species have a striking capacity for regeneration in nature, including regeneration of the entire individual from explants. However, due to the lack of suitable experimental models, the regulatory mechanisms of spontaneous whole plant regeneration are mostly unknown. In this study, we established a novel model system to study these mechanisms using an amphibious plant within Brassicaceae, Rorippa aquatica, which naturally undergoes vegetative propagation via regeneration from leaf fragments. Morphological and anatomical observation showed that both de novo root and shoot organogenesis occurred from the proximal side of the cut edge transversely with leaf vascular tissue. Time-series RNA-seq analysis revealed that auxin and cytokinin responses were activated after leaf amputation and that regeneration-related genes were upregulated mainly on the proximal side of the leaf explants. Accordingly, we found that both auxin and cytokinin accumulated on the proximal side. Application of a polar auxin transport inhibitor retarded root and shoot regeneration, suggesting that the enhancement of auxin responses caused by polar auxin transport enhanced de novo organogenesis at the proximal wound site. Exogenous phytohormone and inhibitor applications further demonstrated that, in R. aquatica, both auxin and gibberellin are required for root regeneration, whereas cytokinin is important for shoot regeneration. Our results provide a molecular basis for vegetative propagation via de novo organogenesis.