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Facts, Views & Vision in ObGyn Sep 2023Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome has an incidence of 1 in 4000. The absence of the vagina and uterus results in sexual dysfunction and infertility. The...
BACKGROUND
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome has an incidence of 1 in 4000. The absence of the vagina and uterus results in sexual dysfunction and infertility. The first-line treatment is vaginal dilatation. There exists a number of second-line surgical options including the Uncu-modified Davydov procedure.
OBJECTIVE
To determine the complication rate, anatomical outcomes, and long-term sexual outcomes of MRKH syndrome patients after Uncu-modified Davydov procedure.
MATERIALS AND METHODS
Patients with MRKH syndrome who underwent paramesonephric remnant-supported laparoscopic double-layer peritoneal pull-down vaginoplasty (aka Uncu-modified Davydov procedure) between January 2008 and December 2021. The procedure involves laparoscopic circular dissection of the pelvic peritoneum followed by pulling down, through the opened vaginal orifice, and suturing the vaginal cuff with the support of uterine remnants. The long-term complication rate, anatomical outcomes, and sexual function outcomes (as measured by Female Sexual Function Index (FSFI)) were ascertained.
MAIN OUTCOME MEASURES
Main Outcome Measures: The long-term complication rate, anatomical outcomes and FSFI survey results.
RESULTS
A total of 50 patients with MRKH syndrome underwent the Uncu-modified Davydov procedure between Jan 2008- Dec 2021. There were four perioperative complications: three bladder injuries (6%) and one rectal serosa injury (2%). Four long-term postoperative complications were identified: one vesicovaginal fistula (2%), one recto-vaginal fistula (2%), and two vaginal stenoses (4%). All patients were physically examined at least one year after surgery. The mean vaginal length was 8.4 + 1.9 cm. The mean FSFI score was 31.5 + 3.9 (minimum score of 24, maximum score of 36).
CONCLUSION
Conclusion: The Uncu-modified Davydov procedure has been demonstrated to be a safe and effective treatment option with high female sexual function index scores for patients with MRKH syndrome.
WHAT IS NEW?
The long-term complication rate, anatomical and sexual outcomes of Uncu-modified laparoscopic peritoneal pull-down vaginoplasty were reported in this study. The results indicated that the surgical approach could be used in selective MRKH patients who failed first-line self-dilatation therapy.
PubMed: 37742200
DOI: 10.52054/FVVO.15.3.091 -
Hellenic Journal of Cardiology : HJC =... Sep 2023Left atrial appendage (LAA) closure (LAAC) procedures are conventionally performed using empirical fluoroscopic viewing angles. However, because the LAA is a highly...
BACKGROUND
Left atrial appendage (LAA) closure (LAAC) procedures are conventionally performed using empirical fluoroscopic viewing angles. However, because the LAA is a highly variable anatomical structure, these angles cannot depict the LAA in the optimal position. The present study aimed to assess the efficiency of using a novel optimal fluoroscopic projection angle (OPA) for LAAC and to validate its feasibility.
METHODS
The OPAs of the derivation cohort were acquired using cardiac computed tomography angiography (CCTA) to assess its superiority for depicting LAA depth versus traditional working angles (TAs) of RAO 30°, CAU 20°. The practicability of OPA-guided LAAC was demonstrated by comparison between clinical data from the validation cohort and those from a propensity-score matched (PSM) control group, as well as randomized controlled studies investigating LAAC.
RESULTS
Of 705 patients in the derivation cohort, the median OPA was RAO 46°, CAU 31°. Compared with TA, the OPA depicted a longer mean (±SD) LAA depth (5.1 ± 4.4) mm and a larger orifice diameter (1.1 ± 1.1 mm), (P < 0.0001 for both). All 38 OPA-guided LAACs were successful, with a shorter mean procedure duration (42.9 ± 12.3 min versus [vs.] 107.2 ± 41.5 min; P < 0.0001) and reduced device consumption (1.08 vs. 1.5 per case), compared with the PSM control group. At the 3-month follow-up, the incidence of peri-device leak was 52.6% (20/38) detected by CCTA, with a mean leakage of 1.6 ± 0.8 mm.
CONCLUSION
By unfolding the LAA depth and orifice diameter for a better view, OPA demonstrated the potential to optimize LAAC procedural efficiency, although further larger-scale studies are required to confirm this.
PubMed: 37717695
DOI: 10.1016/j.hjc.2023.09.009 -
Journal of Minimal Access Surgery Jan 2024Open, pure or hand-assisted laparoscopic, natural orifice transluminal endoscopic surgical (NOTES) and robotic approaches (Transperitoneal or retroperitoneal) are the...
Open, pure or hand-assisted laparoscopic, natural orifice transluminal endoscopic surgical (NOTES) and robotic approaches (Transperitoneal or retroperitoneal) are the described approaches for living donor nephrectomy. We describe the procedural steps of a robotic living donor nephrectomy (RLDN) retroperitoneal (RRLDN) technique using a da Vinci X surgical system and three robotic arms. This is the first reported case with the retroperitoneal robotic approach. The procedure in brief is as follows. First, with the patient placed in full flank position, the camera port is placed at the level of the Petit's triangle apex. Retroperitoneal space is created by turning the index finger in a 180° movement through this port and a gloves balloon. The second 8mm port was inserted, 8 cm far from the first port, The peritoneum is reflected medially and downward off of the transversus abdominis muscle laparoscopically, respectively along the anterior and posterior axillary line; 3-5 cm caudally to the last one, a 12 mm AirSeal® assistant port is placed in the same manner. Only then, the port is placed under direct vision. The robotic ports placement will result in a caudally convex arc. This technique, due to the extensive use of the surgeon index, implies fast access to the retroperitoneum, protects the underlying anatomical structures from damage, and, due to the trocar positioning along an arc, lowers the arm conflict risk.
PubMed: 37706411
DOI: 10.4103/jmas.jmas_29_23 -
Journal of Interventional Cardiac... Apr 2024Recent anatomic and electrophysiologic evidence has provided new insight into the anatomic substrate. Previous reports on electroanatomic mapping (EAM) of the circuit of...
BACKGROUND
Recent anatomic and electrophysiologic evidence has provided new insight into the anatomic substrate. Previous reports on electroanatomic mapping (EAM) of the circuit of atrioventricular nodal reentrant tachycardia (AVNRT) have been limited by mapping only the triangle of Koch on the right side of the septum and by the use of conventional mapping tools. The objectives are to obtain comprehensive high-resolution mapping of typical AVNRT and to investigate the role of the atrioventricular ring tissues in the circuit.
METHODS
We employed EAM with the use of novel modules and algorithms for studying typical AVNRT from the right and the left sides of the septum.
RESULTS
We performed extensive mapping of both the atrial septum and the septal vestibule of the tricuspid valve during typical AVNRT in 9 (6 females) patients, aged 49.6 ± 12.1 years. In two of these, left septal mapping was also obtained through the aorta. The earliest initial activation was variable, emanating from the superior or medial septum. The impulse consistently appeared below the orifice of the coronary sinus, at the site where its inferoanterior margin merged with the septal vestibule of the tricuspid valve at its entrance to the right atrium. It then returned to the initial activation site, presumably through the septal vestibular myocardium. The left septal activation area corresponded to that recorded on the right side.
CONCLUSIONS
Typical AVNRT uses a circuit confined within the pyramid of Koch from the AV node to the septal isthmus, involving the myocardial walls of the pyramidal space.
Topics: Female; Humans; Tachycardia, Atrioventricular Nodal Reentry; Atrioventricular Node; Heart Atria; Atrial Septum; Myocardium; Catheter Ablation; Electrocardiography
PubMed: 37691082
DOI: 10.1007/s10840-023-01632-7 -
Revista Brasileira de Ortopedia Aug 2023To evaluate the technical reproducibility of a block of the pericapsular nerve group (PENG) of the hip aided or not by ultrasound in cadavers. The present is a...
To evaluate the technical reproducibility of a block of the pericapsular nerve group (PENG) of the hip aided or not by ultrasound in cadavers. The present is a randomized, descriptive, and comparative anatomical study on 40 hips from 2 cadaver groups. We compared the PENG block technique with the method with no ultrasound guidance. After injecting a methylene blue dye, we verified the dispersion and topographical staining of the anterior hip capsule through dissection. In addition, we evaluated the injection orifice in both techniques. In the comparative analysis of the techniques, there were no puncture failures, damage to noble structures in the orifice path, or differences in the results. Only 1 hip from each group (5%) presented inadequate dye dispersion within the anterior capsule, and in 95% of the cases submitted to either technique, there was adequate dye dispersion at the target region. Hip PENG block with no ultrasound guidance is feasible, safe, effective, and highly reliable compared to its conventional counterpart. The present is a pioneer study that can help patients with hip pain from various causes in need of relief.
PubMed: 37663182
DOI: 10.1055/s-0042-1758367 -
Journal of the American Heart... Sep 2023Background Short-term effects on mitral valve (MV) anatomy after transcatheter edge-to-edge repair using the PASCAL system remain unknown. Precise quantification might...
Background Short-term effects on mitral valve (MV) anatomy after transcatheter edge-to-edge repair using the PASCAL system remain unknown. Precise quantification might allow for an advanced analysis of predictors for mean transmitral gradients. Methods and Results Consecutive patients undergoing transcatheter edge-to-edge repair for secondary mitral regurgitation using PASCAL or MitraClip systems were included. Quantification of short-term MV changes throughout the cardiac cycle was performed using peri-interventional 3-dimensional MV images. Predictors for mean transmitral gradients were identified in univariable and multivariable regression analysis. Long-term results were described during 1-year follow-up. A total of 100 patients undergoing transcatheter edge-to-edge repair using PASCAL (n=50) or MitraClip systems (n=50) were included. Significant reductions of anterior-posterior diameter, annular circumference, and area throughout the cardiac cycle were found in both cohorts (<0.05 for all). Anatomic MV orifice area remained larger in the PASCAL cohort in mid (2.8±1.0 versus 2.4±0.9 cm; =0.049) and late diastole (2.7±1.1 versus 2.2±0.8 cm; =0.036) compared with the MitraClip cohort. Besides a device-specific profile of independent predictor of mean transmitral gradients, reduction of middiastolic anatomic MV orifice area was identified as an independent predictor in both the PASCAL (=-0.410; =0.001) and MitraClip cohorts (=-0.318; =0.028). At follow-up, reduction of mitral regurgitation grade to mild or less was more durable in the PASCAL cohort (90% versus 72%; =0.035). Conclusions PASCAL and MitraClip showed comparable short-term effects on MV geometry. However, PASCAL might better preserve MV function and demonstrated more durable mitral regurgitation reduction during follow-up. Identification of independent predictors for mean transmitral gradients might potentially help to guide device selection in the future.
Topics: Humans; Heart Murmurs; Mitral Valve; Mitral Valve Insufficiency
PubMed: 37646220
DOI: 10.1161/JAHA.123.030333 -
Folia Morphologica Aug 2023A single left coronary artery with a single orifice in the left aortic sinus was observed during anatomical practice in an 81-year-old male Japanese cadaver. The single...
A single left coronary artery with a single orifice in the left aortic sinus was observed during anatomical practice in an 81-year-old male Japanese cadaver. The single left coronary artery bifurcated into the anterior interventricular branch (IVa) and circumflex (CXa) branches. The IVa descended into the anterior interventricular sulcus to supply the apex of the heart, leaving a branch that traversed the upper part of the infundibulum to supply the anterior upper region of the right ventricle. The CXa curved leftward in the atrioventricular sulcus to reach the posterior surface, after which it continued to emerge into the anterior surface. The vascular running pattern showed that CXa directly supplied blood to the upper right ventricle (but not the conus branch), with three branches connected to the apex. The atrial arteries showed no anomalous distribution patterns. These findings are useful during surgical procedures, including cardiac catheterization.
PubMed: 37622395
DOI: 10.5603/FM.a2023.0052 -
Journal of Pediatric Urology Feb 2023Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with...
INTRODUCTION
Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure).
OBJECTIVE
With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants.
STUDY DESIGN
A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups.
RESULTS
Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques.
DISCUSSION
RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers.
CONCLUSIONS
Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.
Topics: Infant; Humans; Retrospective Studies; Ureterocele; Endoscopy; Postoperative Period; Surgeons
PubMed: 37590379
DOI: 10.1016/j.jpurol.2022.09.024 -
Europace : European Pacing,... Aug 2023Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized head-to-head trial comparing the Amulet and Watchman 2.5 LAAO devices with fundamentally different designs. The predictors and mechanistic factors impacting differences in PDLs within the Amulet IDE trial are assessed in the current analysis.
METHODS AND RESULTS
An independent core lab analysed all images for the presence or absence of severe PDL (>5 mm). The incidence, mechanistic factors, predictors using propensity score-matched controls, and evolution of severe PDLs through 18 months were assessed. Of the 1878 patients randomized in the trial, the Amulet occluder had significantly fewer severe PDLs than the Watchman device at 45 days (1.1 vs. 3.2%, P < 0.001) and 12 months (0.1 vs. 1.1%, P < 0.001). Off-axis deployment or missed lobes were leading mechanistic PDL factors in each device group. Larger left atrial appendage (LAA) dimensions including orifice diameter, landing zone diameter, and depth predicted severe PDL with the Watchman device, with no significant anatomical limitations noted with the Amulet occluder. Procedural and device implant predictors were found with the Amulet occluder attributed to the learning curve with the device. A majority of Watchman device severe PDLs did not resolve over time through 18 months.
CONCLUSION
The dual-occlusive Amplatzer Amulet LAA occluder provided improved LAA closure compared with the Watchman 2.5 device. Predictors and temporal observations of severe PDLs were identified in the Amulet IDE trial.
CLINICAL TRIAL REGISTRATION
https://clinicaltrials.gov Unique identifier NCT02879448.
Topics: Humans; Atrial Appendage; Atrial Fibrillation; Cardiac Surgical Procedures; Treatment Outcome; Septal Occluder Device; Cardiac Catheterization; Stroke
PubMed: 37584233
DOI: 10.1093/europace/euad237