Transurethral Incision of the Bladder Neck with Additional Procedure Resumes Spontaneous Voiding in Female Voiding Dysfunction – A Long-term Follow-up

Introductions: To evaluate the long-term effectiveness of transurethral incision of the bladder neck (TUI-BN) with or without additional procedure for female voiding dysfunction.Methods: Women with voiding difficulty and underwent TUI-BN in recent 12 years were included. All patients underwent videourodynamics study (VUDS) at baseline and after TUI-BN. Successful outcome was defined as having a voiding efficiency (VE) by ≥50% after treatment. Patients with insufficient improvement were opt for repeated TUI-BN, urethral onabotulinumtoxinA injection or transurethral external sphincter incision (TUI-ES). The current voiding status, surgical complications were evaluated.Results: A total of 102 women with VUDS evidence of a narrow bladder neck during voiding were enrolled. The long-term success rate of the first TUI-BN was 29.4% (30/102) and increased to 66.7% (34/51) after combining TUI-BN and additional procedure. The overall long-term success rates were 74.6% in detrusor underactivity (DU), 52.0% in detrusor overactivity and low contractility, 50.0% in bladder neck obstruction (p=0.022). Spontaneous voiding was achieved in 66 (64.7%) patients, de novo urinary incontinence in 21 (20.6%), and vesicovaginal fistula in 4 (3.9%), all were repaired.Conclusions: TUI-BN alone or in combination with additional procedure was safe, effective and durable. Patients with DU benefit most in resuming spontaneous voiding.

Safety and Efficacy of a Modified Technique of Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is a valid alternative to transurethral resection of the prostate and open simple prostatectomy for the treatment of a larger prostate, demonstrating comparable efficacy and lower morbidity. One of the most bothersome symptoms after HoLEP is urinary incontinence (UI), which is present in almost 20% of patients, with a recovery rate of over 80% at 3 months. A relevant risk factor linked to UI is the damage of the external sphincter during the enucleation of adenoma tissue close to it. In our modified HoLEP technique named Cap HoLEP, we preserve the anterior prostate portion proximal to the external sphincter. This cap of adenoma could reduce mechanical stress and laser energy widespread on the sphincter, acting as a protective barrier. The aim of this study was to describe the Cap HoLEP technique and to evaluate its safety and efficacy by assessing peri-operative and functional outcomes. We enrolled all patients who consecutively underwent Cap HoLEP from December 2017 to October 2019 in our hospital. Baseline characteristics; the International Prostate Symptom Score; uroflow findings; intraoperative data, intraoperative, and postoperative complications; and UI were all assessed. The median operative time was 122 min with 138 kJ of laser energy delivered. Median ∆Hb was 0.8 gr/dL. Seven low-grade complications were recorded. At 1 month, 34.8% of patients presented UI, 16.7% urge incontinence, 13.6% stress incontinence, and 4.5% mixed incontinence. At 3 months, UI showed a significant improvement, decreasing to 12.1%. At 6 and 12 months, UI was 7.6% and 3%, respectively. Our modified HoLEP technique is safe and effective, allowing significant improvement in the postoperative UI rate.

On the question of the peripheral innervation of the rectum. Critical and experimental research

All experiments were made by you 56. Of these, 10 experiments with negative pressure, 8 experiments with double registration (according to Courtade and Guyon` y), 15 with simultaneous registration of three bowel sections (colonis, recti and sphinct. Inter.), 4 experiments with irritation spinal roots, 2 experiments for examining the external sphincter. The remaining 17 embrace the usual experiments of investigating the movements of the recti under the influence of the irritated intestinal nerves according to the method indicated by us in the beginning of our work; this also included 5 experiments with combined irritations n. erigentis and n. hypogastrici.

Is an empirical approach to performing access in pediatric surgery in children safe?

Objective: to determine the topical localization of the structural components of the anal sphincter and to formulate the basic postulates of the formation of safe anatomical access in pilonidal disease surgery in children. Materials and methods: the study was conducted on the corpses of 10 children who had no lifelong pathology of the sacrococcygeal region and pelvis aged 12 to 17 years, including 5 girls and 5 boys. Soft tissue columns 1 cm wide and up to 5 cm long were prepared at a distance of 1 cm from the anus by 12 h, 3 h, 6 h and 9 h according to the dial in the back position. After preparation and fixation of the drugs, their staining was performed and cross-sections of anal sphincters 5–7 μm thick were made. The analysis of the received morphometric data is carried out. The results of the study: it was found that the cross-sectional area of the bundle of muscle fibers of the external sphincter of the anus on average in adolescents ranged from 448±32 μm2 to 412±24 μm2. The diameter of its muscle fibers was 13.02±1.56 μm, and the bulk density of muscle fibers is 96.12±1.34%. Regarding the length of the internal anal sphincter, it was found that it is almost the same in different areas and is 1.3±0.03 at the level of 3 and 12 hours, 1.3±0.07 at the level of 6 hours and 1.2±0.03 at the level of 9 hours. In the study of the linear dimensions of the length of different portions of external anal sphincter in certain places of the biopsy revealed a predominance of parameters that were determined at 6 hours, respectively, 5.7±0.06 cm against 4.3±0.04 cm at 3 hours, and 12 hours, respectively 5.1±0.06 cm against 4.3±0.03 cm at 9 years. The thickness of the external sphincter of the anus at 6 hours, respectively 26.7±0.61 mm against 18.5±0.19 mm at 3 hours, (<0.01) and 12 hours, respectively 23.9±0.33 mm against 18.4±0.19 mm at 9 hours. Diameters of separate muscular fibers and bundles were explored. It is established that the average diameter of a muscle fiber makes 13.7±0.18 microns, and the average diameter of a muscular bundle is equal to 435.9±5.15 microns. Conclusions. 1. Existing anatomical descriptions of anal sphincters need in the modern world more thorough research to prevent their injury during surgery. 2. The external anal sphincter has the spatial form of the three-storeyed oval structure extended in the front-back direction with dominance of the caudal muscular portion. 3. When performing radical surgical interventions for pilonidal disease in children by cleft-lift method, it is necessary to complete the edge of surgical access at a distance of not less than 3 cm to the edge of the anal sphincter. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: pilonidal disease, children, morphometry, surgical intervention.

A Case of Large Perianal Mucinous Adenocarcinoma Arising from Recurrent Abscess and Complex Fistulae

Mucinous adenocarcinoma of the perianal region is an oncologic rarity posing a diagnostic and therapeutic dilemma for treating oncologists. This is due to the low number of reported cases, compounded by the lack of definitive therapeutic guidelines. It accounts for 2% to 3% of all gastrointestinal malignancies and is historically known to arise from chronic anal fistulas and ischiorectal or perianal abscesses. We hereby report an interesting case of perianal mucinous adenocarcinoma in a 66-year-old male initially treated for a horseshoe abscess with complex fistulae. He presented with a 6-month history of a discharging growth in perianal region and painful defecation associated with occasional blood mixed stools. An incisional biopsy from the ulcer revealed mucinous adenocarcinoma. Contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) scan showed a localized perianal growth which involves the internal and external sphincter as well as suspicious involvement in the posterior aspect of the levator ani/puborectalis sling, which was further confirmed with colonoscopy (see figures). With no preset treatment protocol for this rare entity, he was managed with an abdominoperineal resection (APR) and vertical rectus abdominis myocutaneous flap (VRAM) tissue reconstruction. He had a turbulent postoperative period including intestinal obstruction secondary to internal herniation of bowel resulting in flap failure. The subsequent perineal wound was managed conservatively with advanced wound care and has since completely healed.

Power of 3D Transrectal Ultrasonography and Magnetic Resonance Imaging in Diagnosis of Cryptogenic Rectal Fistulae

Background. The only radical curative treatment for rectal fistulae is surgery. The choice of surgery requires precise characterisation of the fistulous tract. The most common instrumental methods for rectal fistula diagnosis are transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI).Objectives. Comparative assessment of the diagnostic power of 3D TRUS and MRI techniques in revealing cryptogenic anal fistulae with respect to intraoperative examination.Methods. The study enrolled 92 patients with rectal fistulae aged 27 to 66 years. Fistulous opening was external in 47 (51.1%) and obliterated in 45 (48.9%) patients. The average patient age was 42.7 ± 15.9 years. Surgery for acute paraproctitis 14 to 32 days prior to examination was in history of 58 (63.1%) patients. All patients had preoperative subsequent 3D TRUS and MRI compared with intraoperative examination results.Results. The rate of correct fistulous tract type diagnosis verified with intraoperative revision was 96.7% (89/92) with 3D TRUS and 82.6% (76/92) with MRI (p = 0.0027). The error rate of 3D TRUS estimation of external sphincter involvement was 1.1% (1/92), sensitivity 96.6%, specificity 93.5%, overall accuracy 94.5%. The MRI error rate was 21.7% (20/92), with a statistically significant difference for sensitivity and overall accuracy (p < 0.0001). The rate of correct estimation of internal fistulous localisation in “anorectal clock” was 97.8% (90/92) with 3D TRUS and 90% (81/90) with MRI (p = 0.0342). Internal fistula was not detected with MRI in 2/92 (2.2%) cases, which explains the deviation. Intraoperative revision identified total 113 abscesses. The rate or correct abscess estimation was 97.3% (110/113) with 3D TRUS and 74.7% (71/95) with MRI. MRI failed to detect abscess in 18/113 (15.9%) cases (p < 0.0001).Conclusion. 3D transrectal ultrasonography is statistically superior over magnetic resonance imaging in estimating internal fistula localisation in “anorectal clock”, fistulous type, as well as the fistulous tract location relative to external sphincteric tissue in patients with transsphincteric anal fistulae. Estimation of pararectal and intramural abscesses was also significantly different.