Tension-Free Inguinal Hernia Repair in Local Anaesthesia versus Spinal Anaesthesia

Background: Inguinal hernia is a common presentation in surgical clinics. In the past, the hernia surgeries were done under general and spinal anesthesia. Recently local anesthesia is being increasingly used due to the increased efficacy of local anesthetics and economic reasons. We in the current study tried to evaluate the effectiveness of Lichtenstein repair under local anesthesia and spinal anesthesia and the overall outcomes of both methods. Methods: This cross-sectional study was conducted in the Department of General Surgery, Prathima Institute of Medical Sciences, Naganoor, Karimnagar. Successive cases of uncomplicated inguinal hernia were selected for the study. A total of n=60 cases randomly allotted in two groups The LA group and SA group were taken and studied. Post-operatively VAS scale was used to evaluate pain, other postoperative complications such as testicular swelling and pain, urinary retention, nausea/vomiting, postural hypotension, and wound infections were recorded. Results : The age of the patient varied from 20 to 80 years with the highest prevalence noted in the age group of 41 to 60 years. The Mean age of presentation is 51.3 years. The anatomical location and type of hernia are given in table 1. 60.9% of inguinal hernia in this study was an indirect type, 30.4% was direct, 6.5% was pantaloons type and 2.2% was Ogilvie's hernia. Out of 74 patients, 62.1% had a right-sided inguinal hernia compared to the left side which accounted for 37.8%. Complication records showed N=9(23.7%) of the SA group and n=8(22.2%) LA group developed scrotal edema and in total n=17(23%) developed scrotal edema. N=7(18.4%) patients in the SA group and n=7(19.4%) in the LA group developed seroma and in total patients, n=14(18.9%) developed seroma. Conclusion: Lichtenstein tension-free hernioplasty done under local anesthesia is with less immediate postoperative complications, also the best suitable for patients with medical comorbidities and those who are on antiplatelet therapy where spinal anesthesia is contraindicated.

Minimal change disease following the Moderna COVID-19 vaccine: first case report

Background There have been cases of minimal change disease (MCD) reported following previous vaccines. During the COVID-19 era, only 3 cases of new-onset MCD and a case of MCD relapse were reported following the Pfizer-BioNTech COVID-19 vaccine. We herein report the first case of MCD after receiving the Moderna COVID-19 vaccine. Case presentation A 43-year-old man presented to hospital 3 weeks after receiving the first dose of the Moderna vaccine, with both bilateral lower extremities and scrotal edema. He initially developed a sudden-onset bilateral lower extremities swelling on day 7 post-vaccine. He, then, developed dyspnea and scrotal swelling over a time span of 2 weeks. On physical examination, his blood pressure was 150/92 mmHg. There was a decreased air entry at lung bases, bilateral lower extremities and scrotal edema. Labs revealed hypoalbuminemia, hyperlipidemia and 15 g of proteinuria. His immunologic and serologic work up was negative. Renal biopsy showed concomitant MCD and IgA nephropathy. Patient was treated with oral steroids and had a good response; his edema resolved, serum albumin improved, and proteinuria decreased to 1 g within 2 weeks of treatment. Conclusions To the best of our knowledge, MCD has not been previously reported after receiving the Moderna COVID-19 vaccine. It remains unclear whether the COVID-19 mRNA vaccines are associated with the development of MCD, or it coincided with the mass vaccination. Further studies are needed to determine the incidence of MCD post COVID-19 vaccines and the underlying pathophysiology of glomerular injury post vaccination.

Single Median Raphe Scrotal incision Orchiopexy: A safe & feasible approach for fixation of Palpable Undescended testes

Background: We wish to share our outcome of single median raphe scrotal incision orchiopexy (SMRSO) regarding safety & feasibility of technique by evaluating ease of access, conversion rate, duration of surgery, success rate, complications, and the need for redo-surgery. Methods: We retrospectively analyzed data of 277 orchiopexies performed in our department on 224 patients operated on between June 2016 to June 2019. SMRSO was considered for palpable testes that can be brought to the upper limit of the scrotum under anesthesia. The conventional inguinoscrotal approach was used for high lying testes. A median raphe incision was made to access & mobilize the testis on either side, ligation of processus vaginalis performed, and the testes secured in the scrotal pouch. The approach was utilized for both unilateral and bilateral orchiopexies. Follow-up done at one week, one month & six months to evaluate the outcome. Results: A total of 277 orchiopexies were performed in 224 patients. 237 (86%) orchiopexies were via the median raphe scrotal approach in 184 patients. Out of these, 53 cases had bilateral orchiopexies. 30 (11%) performed via a conventional inguinoscrotal approach and 10 (4%) by laparoscopic approach. The mean duration of surgery for SMRSO was 24 minutes for unilateral and 42 minutes for bilateral cases. Immediate postoperative complications included scrotal hematoma in three (1.6%) cases, Hematoma of the abdominal wall in one case, and scrotal edema in 4 (2%) patients. All complications were treated conservatively & resolved. No wound infection or testicular atrophy was reported. Long-term complications included testicular ascend in three cases [1.6%]. Conclusion: Single-incision Median Raphe Scrotal orchiopexy is an attractive alternative to the standard inguinoscrotal orchiopexy for palpable low lying undescended testes with a better cosmetic outcome. doi: https://doi.org/10.12669/pjms.37.7.4261 How to cite this:Jan IA, Hassan M, Shalaan I, Alshehhi MA. Single Median Raphe Scrotal incision Orchiopexy: A safe & feasible approach for fixation of Palpable Undescended testes. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4261 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

MO718ROLE OF CT-PERITONEOGRAPHY IN THE PATIENT WITH GENITAL EDEMA AND PERITONEAL DIALYSIS

Background and Aims Genital edema is a frequent complication in those patients who are on peritoneal dialysis, generally secondary to the increase in intra-abdominal pressure that it entails. It occurs late after the implantation of the peritoneal catheter (after 30 days of implantation). The typical clinical manifestation of this condition is basically subcutaneous edema in the genital area, accompanied by pain and UF failure. The diagnosis must be made by using an imaging test, mainly CT-peritoneography. Method A series of clinical cases of PD patients who consulted for genital edema is reviewed, analyzing the role of peritoneography Results CASE 1 A 76-year-old male, 15 days after the start of the technique, consulted for right scrotal edema. It was decided to suspend CAPD and start hospital intermittent IPD with low volumes. A CT-peritoneography was requested, which revealed a right peritoneal-vaginal duct and a left inguino-scrotal leak. Surgical correction of the anatomical defect was performed without incident, with subsequent return of the patient to CAPD. CASE 2 A 78-year-old man, 15 days after the start of the technique, consulted for bilateral scrotal edema. A CT-peritoneography was performed, which showed that the leak of peritoneal fluid to the scrotum was due to bilateral inguinal hernia. Subsequently, inguinal hernioplasty of the surgical defect was performed without complications. Conclusion Genital edema, as a complication of patients with CAPD, appears in approximately 4-10% of them. CT-peritoneography is the diagnostic technique of choice. To do this, 150 ml of nonionic iodinated contrast, with a concentration of 300 mg/ml, are diluted in approximately 2 liters of dialysis solution, which are introduced into the peritoneal cavity of the patient 2 h before performing the CT. Subsequently, a CT scan of the abdomen and pelvis including the perineum is performed, in the supine position and craniocaudal direction.

To Evaluate the Outcome of Epididymal Cystectomy at Liaquat Medical College Hospital Jamshoro Pakistan

Introduction: Epididymal cystectomy is the procedure in which removal of cyst attached to epididymis is done. The cyst contains cleat/straw colored fluid. It is excised because of its increasing size causing discomfort or pain to patient. Methodology: A Cross sectional observational study was conducted at Surgical Unit 1, Department of of Surgery LMC Hospital Jamshoro from January 2020 to January 2021. All the patients were admitted through Surgical OPD (SOPD) with cystic swellings in scrotum. History and clinical examination of inguino-scrotal region was done. Transillimination test was also done. Ultrasound was obtained to confirm the diagnosis, number of cysts, sizes and site of cyst. Hydrocele, spermatocele and testicular malignancies were ruled out through investigations. Surgery was planned after getting cardiac and anesthesia fitness. The surgery was done. Patients were shifted to ward and assessed for 3 to 5 days. Patient was called for follow up for 6 months. Results were analyzed using statistical package for social sciences (SPSS) version 23. Results: Total patients included in our study are 49.32 (65%) patients had solitary cyst and 17 (35%) had multiple cysts. 30 (61.2%) patients had left sided epididymal cysts and 19 (38.7%) had right sided cysts. Hematoma was developed by 6.1%, chronic pain by 12.2%, infection by 8.1%, scrotal edema by 10.2% and recurrence by 6.1% patients. Conclusion: Epididymal cystectomy is the procedure with better outcome and least complications rate.

Unusual clinical scenarios in Urology and Andrology

This collection includes some unusual cases and how they were diagnosed and treated. Case 1: A case of a patient with primary hyperthyroidism presenting with a submucosal ureteral stone after endoscopic lithotripsy was described. After multiple endoscopic treatment, the stone was successfully removed by open ureterolithotomy recovering ureteral patency and normal renal function. Case 2: A case of burned-out testicular cancer with atypical lymphatic spread (stage II A) was presented. After right orchiectomy and complete remission of tumor markers, due to atypical metastases location and uncertain histology, the patient was treated with systemic therapy based on bleomycin, etoposide and cisplatin (PEB). At re-staging after chemotherapy computed tomography showed reduction of all node metastases and an observation protocol was proposed. Case 3: A patient was readmitted to hospital after 12 days from an uneventful Robot-Assisted Radical Prostatectomy (RARP) for prostate cancer due to lower abdominal pain plus abdominal distension, nausea and constipation not responsive to medical therapy. Computed Tomography showed colon and small bowel dilatation without any evidence of anatomical or mechanical obstruction. Laparoscopic abdominal exploration confirmed bowel distension without evidence of obstructing lesions. Ogilvie’s Syndrome or acute colonic pseudo-obstruction (ACPO) was diagnosed. The patient fully recovered and was discharged six days after the procedure. Case 4: A case of recurrent Acute Idiopathic Scrotal Edema (AISE) was diagnosed on clinical signs together with the decisive help of pathognomonic ultrasound findings as the “fountain sign”. Case 5: Small bilateral testicular nodules were diagnosed in a 30-years old patient undergoing scrotal ultrasound in follow up of acute lymphoblastic leukemia. Ultrasound guided testis sparing surgery was performed demonstrating Leydig cell tumors.

Diagnosis and management of a scrotal wall mass with the aid of a Scrotoscope: a descriptive observational study

Background and objective: A scrotal wall mass is relatively rare in clinical practice, and very difficult to differentiate from a scrotal content lesion by a physical or ultrasound examination. In this study, we share our experience with the scrotoscope for diagnosing and treating scrotal wall masses. Methods: We retrospectively reviewed all clinical data of scrotal wall mass patients treated by our medical team between June 2015 and July 2019. Diagnostic value was evaluated by comparison with a Doppler ultrasound examination and therapeutic value was evaluated by comparison with traditional surgery. Suspected scrotal tuberculosis or malignant scrotal tumor patients were excluded. Results: Six patients with scrotal wall masses were diagnosed and treated with the scrotoscope. A preoperative ultrasound examination led to an ambiguous or incorrect diagnosis for the origin of the scrotal wall masses in all six cases. The location of all of the masses was confirmed by exploring with the scrotoscope. Three patients were diagnosed with scrotal wall cysts, and one was successfully resected during the procedure; the other two were resected through a small incision. Four scrotal wall solid masses were resected in the other three patients through small incisions after the diagnosis using the scrotoscope. No wound infection, scrotal edema, hematoma, chronic scrotal pain, or injury to the testicles or epididymis were observed. Conclusions: Scrotal wall masses are relatively rare, and it was very difficult to obtain a firm diagnosis of their origin using preoperative ultrasound. The scrotoscope confirmed localization of the tumor, and provided us important information for a minimally invasive resection. Endoscopic resection of a mass can be performed using a scrotoscope.

Acute pediatric peritoneal dialysis: impact of an opt-out model and adaptable methods in a hospital in Nigeria

BACKGROUND Despite efforts to scale peritoneal dialysis (PD) uptake, access is still limited in Sub-Saharan Africa, including Nigeria. Thus, this study evaluated access to PD, cost-effectiveness, complications, and in-hospital mortality rate following the adoption of a local opt-out model approach for all children with acute kidney injury (AKI) that required PD. METHODS This work was a retrospective review of 33 children with AKI that required dialysis between December 2014 and November 2016. PD was carried out using locally adaptable consumables in place of commercially produced consumables. All patients that required renal replacement therapy (RRT) were offered an option to opt-out irrespective of their financial status. Patients’ relevant data were retrieved from the case notes and analyzed. RESULTS The median age was 7 years (range 3–12). 23 patients (70%) were males. Of the 33 patients that required RRT, 29 had PD. The children had an access rate of 88% (95% CI = 76.77–99.03). The access rate was not related to gender (p = 1.000), age group (p = 0.240), or socioeconomic status (p = 0.755). Complications were pericatheter leakage of fluid (n = 7, 24%), catheter malfunction (n = 5, 17%), abdominal wall edema (n = 3, 10%), scrotal edema (n = 2, 7%), and peritonitis (n = 1, 3%). In-hospital mortality was 3/29 (10%; 95% CI = 2.2–27.3). Cost analysis revealed that the cost of consumables was reduced by 88.5%. CONCLUSIONS An opt-out model with the use of locally adaptable consumables improved PD access (88%) with a low in-hospital mortality rate.