The Tough Fibrous Tissue of The Supracondylar Groove As A Useful Landmark Via The Endoscopic Endonasal Approach To The Lower Clivus

Background: The hypoglossal canal (HGC) is the most important structural landmark for the endoscopic endonasal approach to access the lower clivus (LC). We explored the feasibility of using the tough fibrous tissue covering the supracondylar groove (SCG) as a useful landmark to identify the location of the HGC. Methods: Four cadaveric specimens were dissected and analyzed. The craniovertebral junction (CVJ) region was accessed utilizing 4-mm endoscope with either 0° or 30° lenses. CVJ exposure and the surgical corridor areas were measured. The relationship between the tough fibrous tissue covering the SCG and the HGC was analyzed.Results: Tough fibrous connective tissue was tightly attached the SCG and ran superomedially to inferolaterally. The angle between the horizontal plane and the long axis of the SCG was 30°. Separating the tough tissue inferolaterally, we could locate the external orifice (EO) of the HGC to further accurately isolate the hypoglossal nerve. Conclusion: The tough fibrous connective tissue covered the SCG to the upper part of the HGC EO. The course of the tough fibrous connective tissue was superomedial to inferolateral. Using the tough fibrous connective tissue covering the SCG as a landmark, it was possible to accurately locate the HGC EO via the endoscopic endonasal approach to access the LC.

Postcoital cystitis: surgical management

Introduction. Urinary tract infection is one of the most common urological infectious diseases. An important risk factor for uncomplicated urinary tract infection in women is sexual intercourse. Post-coital cystitis is a special form of recurrent cystitis, associated with a low location of the external urethral orifice. This condition is called vestibulo-vaginal dislocation of the urethra. Materials and methods. PubMed and Elibrary (Scientific Electronic Library) databases were searched for studies describing surgical treatment of recurrent post-coital cystitis in women. Based on the relevance and reliability of the sources, 23 articles in peer-reviewed medical journals were selected. All of the selected studies contained data on evolution of surgical treatment approaches for post-coital cystitis. Results. In the middle of the 20th century the interest of medical community in surgical treatment of post-coital cystitis has gradually faded. Such trend was caused by imperfect surgical techniques of existing procedures (O'Donnell and Hirschhorn operations). Subsequent accumulation of experience, over several decades, allowed to establish possible mistakes in diagnosis and operation techniques. Furthermore, a constant search for new techniques and improvement of existing ones minimized potential risk of complications. Great hopes are pinned on the works of B.K. Komyakov et al., who proposed extravaginal transposition of the urethra, that implies the transposition of the urethra and its external orifice as high as possible toward the clitoris. The technique is characterized by high efficacy and a low number of complications, as demonstrated by the treatment results of 228 patients diagnosed with post-coital cystitis. Conclusions. Various curative procedures for post-coital cystitis show the need to determine and standardize the optimal amount of surgical intervention for urethral dystopia in women.

Penile aseptic abscess in the cavernous body at the base of the penis: a case report

We report a case of aseptic abscess in the cavernous body at the base of the penis. In our clinical observation, the patient underwent puncture and drainage of the corpus cavernosum abscess, followed by surgical resection of the abscess wall, with the incisions closed layer by layer with primary suture. In addition, we paid attention to strengthening the postoperative management by using elastic bandages to wrap the penis intermittently to prevent edema; the incision would not be covered with dressings from the third day after the operation, so as to keep the incision site dry in an open way. During the period of indwelling of the catheter after the operation, we noticed the care of the external orifice of the urethra to reduce the occurrence of catheter-related infections. Finally, the patient was diagnosed with a penile aseptic abscess in the cavernous body at the base of the penis. The patient recovered well after surgery and was discharged 1 week later. At 1.5 years after the operation, the shape of the penis returned to normal, and the erectile function was normal. It was seen that good nursing concept is of great help for prognosis, which could avoid infection and edema, and is conducive to wound healing.

Selection of Urethral Orifice Location for Hypospadias with Prostatic Cyst Undergoing Urethroplasty

OBJECTIVE: To explore whether opening the external urethral orifice in the coronal sulcus can reduce the incidence of epididymitis after operating on hypospadias with a prostatic cyst connected to the vas deferens.MATERIALS AND METHODS: Three patients (group A) (average age = 3.3 years old) with severe hypospadias and prostatic cyst underwent cystostomy, hypospadias correction and urethroplasty, along with relocation of the external orifice of urethra. Group B consisted of 4 patients (average age = 6.9 years old) presenting with epididymitis after hypospadias surgery and Unsuccessful conservative treatment. Patients underwent urethral dilatation along with urethral catheterization, cutting of the original corpus cavernosum that encapsulated the urethra, and extension of the position of the external urethral orifice to the coronal sulcus. RESULTS: In group A, 3 children underwent bladder fistula removal 2 weeks after operation. All patients were followed up for 5-7 years. The vulva developed normally without any complications. Four children in group B underwent stent removal 12 weeks after operation, and one patient was still stenosed and dilated again. All patients were followed up for 2-12 years without epididymitis recurrence. Penile erection and ejaculation were normal in adulthood. CONCLUSION: For hypospadias patients experiencing complications due to the presence of a prostatic sac, especially those with prostatic sac connected to the vas deferens, the positioning of the external urethral orifice in the coronary sulcus would be helpful to reduce the occurrence of epididymitis.

The Value and Application of Personalized Needle Modification in Percutaneous Infrazygomatic Radiofrequency in Isolated Maxillary Nerve Pain through the Foramen Rotundum

Background: Percutaneous infrazygomatic radiofrequency (PIR) is a common approach used to block isolated maxillary nerve (V2) pain through the foramen rotundum (FR) in patients with trigeminal neuralgia (TN). Nevertheless, when using this method, there is a risk of accidental penetration of the superior orbital fissure (SOF) and the optic canal (OC) that may result in the injury of the vessels and nerves in that area, and in some severe cases may lead to blindness. According to the blocking of the external orifice of the FR and whether a curved needle was used, combined angle deviation from the path of percutaneous infrazygomatic approach, the FR to the SOF or the OC in the treatment of V2 pain, in which no research has reported the angle, we analyzed the value and application of personalized needle modification in PIR in isolated maxillary nerve pain through the FR. Objectives: The following study examined the relationship between the FR and the SOF, and analyzed the clinical significance of personalized needle modification in computed tomography (CT)-guided PIR ablation of the maxillary nerve through the FR in patients with TN. Study Design: Randomized, review, clinical research study. Setting: Department of Anesthesiology and Pain Medical Center, Jiaxing, China. Methods: Three-dimensional reconstruction was performed in 88 patients and 136 patients with PIR ablation in isolated maxillary nerve pain through the FR. According to the blocking of the external orifice of the FR and whether a curved needle was used, patients were divided into 4 groups: curvedneedle blocking group (CB), straight-needle blocking group (SB), straight needle no-blocking group (SN), and curved-needle no-blocking group (CN). Results: The results obtained revealed minimum H (shortest diameter of the FR) = 1.0 mm and minimum L (length of the FR tubes) = 3.7 mm. The distance between the external orifice of the FR and the SOF (FS) was 5.16 ± 1.33 mm. The angle A (between the radiofrequency needle and the sagittal plane) was 39 ± 3.95°; the angle between the canthomeatal line and the CT scan line (ACT) was 58.99 ± 6.23°; the puncture depth (LS) was 63.99 ± 4.24 mm; the deviation angle of the misplacement into the SOF (SAF) was 2.96 ± 0.71°; the deviation angle of the misplacement into the OC (OAF) was 4.95 ± 0.73°. In addition, the postoperative Numeric Rating Scale scores in the CB group were significantly lower compared with the SB group, whereas the probability of entering the SOF in the CB group was significantly lower compared with the SB group. The total number of punctures in the SN group was less than that in the CN group. Limitations: Additional clinical data should be collected to preserve the results in future work. Conclusions: The distance between the FR and the SOF or the OC was only few millimeters, and slight angle error could lead to the SOF and the OC. For patients with blockage in the path, the treatment of radiofrequency with personalized needle modification could improve the curative effect and reduce the risk of accidental SOF penetration. Key words: Trigeminal neuralgia, foramen rotundum, superior orbital fissure, radiofrequency, personalized needle modification

Urethral Prolapse in a Dog of the American Pit Bull Breed

Background: The urethral prolapse in dogs is a rare condition known by the protrusion of the urethral mucous membrane and the external orifice of the urethra. It is more frequently seen in young males, especially of brachycephalic breeds, for instance the English bulldog. Despite the pathophysiology of this disorder being little elucidated, it is believed that the cause is related to factors such as genetic susceptibility, excessive sexual behavior, traumas, abnormalities and urinary and prostatic problems. Due to limited reports on the subject, this paper aims to describe the clinical and surgical aspects of a case of urethral prolapse in a dog, surgically corrected.Case: Admitted to the Veterinary Hospital of the Federal University of Mato Grosso (HOVET-UFMT) a dog, American Pit Bull, 7 months old, with previous history of bleeding in the penile region and pain while urinating. In the physical exam it presented: intermittent bleeding via external ostium of the urethra, increased volume and protrusion of the distal urethral mucous membrane and the external orifice of the urethra, which was presenting a round shape mass, edematous and little congested of red-purplish coloring, evidenced by the passing of urethral probe. The diagnosis of urethral prolapse was confirmed and, after conducting laboratory tests and obtaining normal results for the species, the animal was sent to surgery. It was opted for the technique of resection and anastomosis of the protruded portion of the mucous membrane. After the anesthetic protocol, it was performed the trichotomy and antisepsis of region, the fenestrated drapes were properly positioned and the urethral catheterization was done, afterwards 3 points of support were produced with nylon thread 3-0, involving the urethra and the external portion of the penis. Subsequently, it was incised 1/3 of the protruded mucous membrane (from a support point to the other) with a pair of iris scissors and the aid of a toothless Adson clamp. Promptly the anastomotic synthesis was manufactured with a simple interrupted suture pattern. By the end of the first one third theremaining ones with go under the same procedure and in the end of the resection and anastomosis of the urethral prolapse the animal was submitted to a bilateral orchiectomy. At the immediate post-surgery it was established antibiotic therapy and the use of anti-inflammatory and painkiller, after 48 h of observation the animal was discharged from the hospital. As a therapeutic measure it was opted to continue with the use of antibiotics and anti-inflammatory, and then recommended the use of Elizabethan collar 24 h a day until the removing of the stitches. It was also recommended that the animal returned for a new evaluation thirteen days after of the procedure.Discussion: That being said, even being an unusual pathology, which the physiopathology is not completely clear, the urethral prolapse is of simple diagnosis, which is based on direct observation of the protruded mucous membrane and by obtaining information of possible factors that cause its appearance, such as genetic susceptibility, in the case of the animalfrom the current report, since it had the English Bulldog as genetic predecessor. Even though there are techniques less traumatic for its diminishing the chosen technique is the resection and anastomose of the protruded portion of the urethral mucous membrane, due to being simple, quick, effective and with lower rates of relapses. Proven by the result of total recovering of the animal and excellent post-surgery healing, not having relapses.Keywords: dog, surgery, urethra.

INTERESFINCTERIAL LIGATION OF FISTULA TRACT (LIFT) FOR PATIENTS WITH ANAL FISTULAS: A BRAZILIAN BI-INSTITUTIONAL EXPERIENCE

ABSTRACT Background : The best treatment for anal fistula should extirpate infection and promote healing of the tract, whilst preserving the anal sphincter complex and full continence. Aim: To analyze the success rate after a modified technique for ligation of the intersphincteric fistula tract (LIFT) for patients with anal fistulas. Methods: A prospective (observational cohort study) Brazilian bi-institutional experience with a modified (ligation of the intersphincteric fistula tract without excision) LIFT technique was undertaken. A clinical database was settled for the following variables: age, gender, BMI, comorbidities, distance between external orifice and the anus, previous fistula surgery, type of fistula, operative time, intra- and postoperative complications, duration of follow-up, and success rate. Results: Between November 2015 and January 2017, 38 patients with transsphincteric fistulas were operated on using the modified LIFT procedure. Seventeen (44.7%) were men. Median age was 41 (18-67) years. Median BMI was 26.4 (22-38) kg/m2. Five (13.2%) had undergone previous surgery. The fistula was transsphincteric in all cases. Median follow-up was 32 (range, 14-56) weeks. Success was observed in 30 (79%) patients. Conclusions: The LIFT technique without excision of the fistula tract proved to be safe and effective for transsphincteric anal fistulas.