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PubMed2003

Reconstruction of burr hole by using autologous button-shaped graft harvested from inner table of craniotomy flap: technique and clinical result.

Patients who underwent craniotomy occasionally complain about the postoperative cosmetic appearance at the site of burr holes on the scalp. This problem occurs as a result of depletion of the skin into the unreconstructed burr holes. Some materials have been developed for reconstruction of craniotomy burr holes. To prevent the postoperative cosmetic deformity, the authors developed a button-shaped autologous bone graft harvested from the inner table of craniotomy flap. Clinical application of this method is described.

Bone Transplantation↗
PubMed1999

Feminizing genital reconstruction, sigmoid vaginal replacement and anorectoplasty as a one-stage procedure for anorectal atresia associated with ambiguous genitalia.

Anorectal atresia associated with male pseudohermaphroditism presents both diagnostic and surgical challenges. In the past, multiple operations were necessary for feminizing genitoplasty in gender-reassigned children with ambiguous genitalia. We combined the repair of an imperforate anus with a feminizing genitoplasty, including sigmoid vaginal replacement using the posterior sagittal approach in a 3-months-old infant. We conclude that a primary complete reconstruction is advantageous and should be performed in this condition.

Anus, Imperforate↗
PubMed2001

Vaginal creation for müllerian agenesis.

OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 +/- 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 +/- 9.5 and 65.3 +/- 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 +/- 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 +/- 12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.

Dilatation↗
PubMed2003

Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in vaginal agenesis.

OBJECTIVE: The purpose of this study was to present our experiences of an innovative surgical approach for vaginal agenesis with the use of Interceed absorbable adhesion barrier (Ethicon) to achieve a satisfactory neovagina. STUDY DESIGN: The current study involved 10 subjects who were diagnosed with vaginal agenesis. After the creation of a vaginal tunnel, a mold that had been wrapped with Interceed was placed in the neovagina. RESULTS: No operative and postoperative complications were encountered. The duration of the operation was < or =30 minutes, and blood loss was minimal. The postoperative hospital stay was only 2 days. Epithelialization of the neovagina was achieved 1 to 4 months after the operation, and all patients were satisfied with the outcome. The neovagina that was created with this procedure was not much different from the normal adult vagina as far as histologic and physiologic conditions are concerned. CONCLUSION: This innovative surgical procedure may be a potential alternative approach for the therapy of vaginal agenesis with the use of the absorbable adhesion barrier Interceed with excellent results.

Adolescent↗
PubMed2000

End-to-side pudendal nerve anastomosis for the creation of a new reinforcing anal sphincter in dogs.

BACKGROUND: An ideal reinforcing neo-sphincter should be innervated by the pudendal nerve to work in coordination with the external anal sphincter. The aim of this study was to create a skeletal muscle innervated by the pudendal nerve without inducing external anal sphincter morbidity. METHODS: Seven dogs were used. On the right side of each dog, the distal end of the transected nerve innervating the biceps femoris muscle was anastomosed to the perineural window of the pudendal nerve, where the epineurium was excised over a small area without injuring the funiculus. Reinnervation was studied 5 months after the operations. The left side of the dogs was used as a control. RESULTS: For all 7 dogs, there was no macroscopic difference detected in the external anal sphincter. For 6 dogs, the biceps femoris muscle was preserved after end-to-side pudendal nerve anastomosis. After the pudendal nerve central to the anastomosis site was electrically stimulated, the external anal sphincter contracted in all dogs. After end-to-side pudendal nerve anastomosis, the biceps femoris muscle contracted with the evoked potential in 5 dogs (71%) and demonstrated electric activity at rest in 3 dogs (43%), but there was no reflex activity after anal stimulation. The ratio of type 1 to type 2 muscle fiber in the biceps femoris muscle after end-to-side pudendal nerve anastomosis significantly changed and became the same as that in the external anal sphincter. The diameter of type 2 muscle fibers in the biceps femoris muscle significantly decreased after surgery. In addition, regenerated myelinated axons were observed in a cross section of the anastomosed nerve in 6 dogs. CONCLUSIONS: End-to-side pudendal nerve anastomosis is a promising technique for the creation of an anal sphincter in patients who have fecal incontinence. The technique preserved the original external anal sphincter and created a skeletal muscle that was innervated by the pudendal nerve in 71% of the dogs studied. This newly innervated skeletal muscle was capable of contracting in coordination with the original external anal sphincter on electric stimulation and also demonstrated characteristics closely similar to those of the external anal sphincter.

Anal Canal↗
PubMed2001

Surgically created double-orifice left atrioventricular valve: a valve-sparing repair in selected atrioventricular septal defects.

OBJECTIVES: Some features of the left atrioventricular valve (large mural leaflet, dystrophic tissue) represent a challenge for repair of atrioventricular septal defects without postoperative regurgitation. A retrospective study was conducted to evaluate the results of surgically creating a double-orifice left atrioventricular valve in such circumstances. Clinical results were analyzed according to valvular and subvalvular left atrioventricular valve measurements in pathologic specimens with atrioventricular septal defects. METHODS: Among 157 patients operated on for atrioventricular septal defect since October 1989, 10 patients underwent primary repair (n = 8) or reoperation (n = 2) by this procedure. Median age at repair was 3.3 years (0.1-33 years). Anatomic types were complete (n = 3), intermediate (n = 5), and partial (n = 2). Preoperative moderate to severe left atrioventricular valve regurgitation was present in 6 patients. After the repair (two-patch technique in complete atrioventricular septal defect, cleft closed in each case), these 10 patients were found to have moderate to severe residual regurgitation not amenable to repair by annuloplasty. The top edge of the mural leaflet was anchored to the facing free edge of the cleft. RESULTS: No hospital death or morbidity was observed. Left atrioventricular valve regurgitation was absent or trivial (8 patients) and mild (2 patients). Color-coded echocardiography did not show significant left atrioventricular valve stenosis. The mean diastolic pressure gradient across the left atrioventricular valve was 3.2 +/- 1.1 mm Hg (1.4-4.5 mm Hg). At a median follow-up of 72 months (6-91 months), there was 1 late death, unrelated to left atrioventricular valve malfunction, due to pulmonary vascular obstructive disease. Left atrioventricular valve regurgitation did not increase over time, except in 1 patient in whom regurgitation recently progressed from mild to moderate. At rest, the mean diastolic pressure gradient across the left atrioventricular valve was 3.8 +/- 2.9 mm Hg (1.5-11.2 mm Hg). One child had an early moderate stenosis without pulmonary hypertension. Studies on pathologic specimens (n = 34) indicated that long chordal lengths and large mural leaflet size are essential independent anatomic features to assess its feasibility. CONCLUSIONS: Surgical creation of a double-orifice left atrioventricular valve is an effective additional procedure for repair of atypical cases of atrioventricular septal defect. The operation may decrease the need for reoperation or left atrioventricular valve replacement.

Adult↗
PubMed2002

Laurence-Moon-Biedl syndrome with vaginal atresia.

A 15-year-old girl presented with the rare Laurence-Moon-Biedl syndrome, accompanied by vaginal atresia, and cervical dysgenesis. She was treated by hysterectomy and construction of a neovagina with bilateral pudendal thigh flaps. Two brothers and a sister (one of twins) were unaffected but the remaining brother also had the disease.

Adolescent↗
PubMedDate not supplied

A model of tissue-engineered ventral hernia repair.

We have developed a tissue-engineered ventral hernia repair system using our novel aligned collagen tube and autologous skeletal muscle satellite cells. In this model system, skeletal muscle satellite cells were isolated from a biopsy, expanded in culture, and incorporated into our collagen tube scaffold, forming the tissue-engineered construct. We characterized the results of the repaired hernias on both the gross and microscopic scales and compared them to an unrepaired control, an autologous muscle repair control, and a collagen-tube-only repair. Untreated animals developed a classic hernia sac, devoid of abdominal muscle and covered only with a thin layer of mesothelial tissue. Significant muscle, small-diameter blood vessels, and connective tissue were apparent in both the autologous control and the engineered muscle repairs. The engineered muscle repairs became cellularized, vascularized, and integrated with the native tissue, hence becoming a "living" repair. A tissue-engineered construct repair of ventral hernias with subsequent incorporation and vascularization could provide the ultimate in anterior wall myofascial defect repair and would further the understanding of striated muscle engineering. The knowledge gained from our model system would have immediate application to mangled extremities, maxillofacial reconstructions, and restorative procedures following tumor excision in other areas of the body.

Animals↗
PubMed2001

Laparoscopic orthotopic ileal neobladder.

BACKGROUND AND PURPOSE: Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer. To our knowledge, presented herein is the initial report of laparoscopic orthotopic ileal neobladder following cystectomy that was performed completely intracorporeally in a porcine model. MATERIALS AND METHODS: The laparoscopic technique was developed in seven pigs. Subsequently, a long-term survival study was performed in 12 consecutive animals. Laparoscopic cystectomy was performed, preserving the urethral sphincter. An ileal segment of 35 cm (first three animals), 45 cm (next four), or 55 cm (final five animals) with adequate mesentery was isolated; and ileal continuity was restored intracorporeally by a stapled anastomosis. Ileal detubularization for construction of an ileal neobladder, urethroileal anastomosis, and bilateral stented ileoureteral anastomoses to a tubular Studer limb extension were all created completely intracorporeally using only laparoscopic free-hand suturing and knot-tying. Biochemical data (preoperative and serial postoperative hemoglobin, renal panel, blood gases), radiologic studies (intravenous urogram, retrograde pouchgram), functional measures (neobladder urodynamics, Whitaker pressure-flow study of both ureters), and microscopic evaluation of the neobladder and ureteroileal and urethroileal anastomotic sites were obtained to evaluate the long-term functional and anatomic outcome. RESULTS: Completely intracorporeal laparoscopic construction of an ileal orthotopic neobladder was successful in all 12 animals without intraoperative or early postoperative complications or open conversion. The mean operating time was 5.4 hours (range 4.5-6.5 hours), and the blood loss was minimal. All study pigs survived their predetermined follow-up period, ranging from 1 to 3 months. Late complications occurred in three animals: one port-site abscess and two cases of E. coli pyelonephritis and azotemia, leading to one death at 2 months. The mean serum creatinine concentrations were 1.33 mg/dL, 1.61 mg/dL, and 1.55 mg/dL at 1, 2, and 3 months, respectively. The mean neobladder capacity was 420 mL (range 250-700 mL) with pressures < or = 20 cm H2O (range 17-20 cm H2O). Pre-euthanasia Whitaker testing confirmed excellent drainage in all 24 ureters. No ileoureteral or ileourethral anastomotic strictures or leaks were noted on intravenous urography, retrograde pouchgram, or postmortem physical calibration of the anastomotic sites. Histologic examination confirmed excellent healing without obvious fibrosis. CONCLUSION: Laparoscopic construction of an orthotopic neobladder is feasible. The anatomic and functional outcome is excellent and comparable to that of open surgery. Clinical application is imminent.

Animals↗
PubMed2001

Recurrent urethral hairball and stone in a hypospadiac: management and prevention.

A 32-year-old perineal hypospadiac man presented with recurrent urethral hair growth, stone, and stricture with a history of multiple urethroplasties. He was treated by urethrolithotomy, internal urethrotomy, laser epilation of the hair-bearing urethral graft, closure of the fistula, and chemical depilation of the neourethral hair. A dilute solution of thioglycolate was prophylactically instilled into the neourethra at intervals of 3 months to ensure complete tricholysis and to prevent recurrent hair growth in the future.

Adult↗
PubMed2006

Case report: Laparoscopy-assisted urinary undiversion: transforming an ileal conduit into an orthotopic continent neobladder.

PURPOSE: To describe the technique of laparoscopy-assisted undiversion of an ileal conduit into a continent orthotopic ileal neobladder performed on a patient with a previous radical cystoprostatectomy and ileal conduit. CASE REPORT: A 57-year-old man presented with a prolapsed stoma and a history of a right radical nephroureterectomy for grade 3 ureteral transitional-cell carcinoma and a radical cystoprostatectomy and ileal conduit urinary diversion for in-situ bladder carcinoma, performed 12 and 8 years ago, respectively. After the ileal stoma was resected, five trocars were placed transperitoneally. Partial resection of the distal ileal conduit was performed, leaving in place the proximal segment with its left ureteroileal anastomosis. Flexible urethroscopy revealed a contracting external sphincter, and random urethral frozen-section biopsies ruled out tumor. A 45-cm segment of ileum was isolated and exteriorized through the stoma site, and an ileal neobladder was created extracorporeally, suturing the proximal ileal-conduit segment, with its ureteroileal anastomosis, to it. The ileal neobladder was reintroduced into the abdomen and anastomosed laparoscopically to the urethral stump with six 2-0 polyglactin sutures. The total operative time was 7 hours with a blood loss of 100 mL. There were no intraoperative complications. The hospital stay was 7 days. At a follow-up of 24 months, the patient had total daytime continence and normal renal function, and intravenous urography revealed an unobstructed urinary tract. CONCLUSION: Laparoscopy-assisted ileal-conduit undiversion into an orthotopic ileal neobladder is technically feasible. It can be considered an alternative to open surgery for patients who have undergone urinary diversion.

Carcinoma, Transitional Cell↗
PubMed2005

Total endoscopic vaginal reconstruction in a case of Mayer-Rokitansky-Kuster-Hauser syndrome.

The congenital absence of the vagina is an uncommonly encountered malformation, known as Rokitanski- Kuster-Hauser syndrome. These patients may enjoy an improved quality of sexual life once a neovagina is constructed. Surgical and nonsurgical (Frank's autodilatation) methods of creating a neovagina by recurrent dilatations require long and often embarrassing self-catheterization which is often painful, and yield a vagina with limited length. The developing ability to perform complicated surgery by laparoscopy has revived interest in colonic and ileal interposition procedures for formation of a neovagina. We report a case of sigmoid colpoplasty for neovagina creation in a 15-year-old girl, performed completely by laparoscopy, with a favorable outcome and an easier recovery.

Adolescent↗
PubMed2003

Use of autologous buccal mucosa for vaginoplasty: a study of eight cases.

BACKGROUND: Vaginal agenesis is a rare condition and treatment methods are varied. The difference between most of the surgical techniques is the graft material used. The purpose of this study was to describe the procedure and outcome of creating a neovaginal pouch lined with autologous buccal mucosa. METHODS AND RESULTS: Between August 2000 and February 2002, eight patients with Mayer-Rokitansky-Kuster-Hauser syndrome were admitted to our hospital. All of the patients successfully underwent neovaginoplasty with autologous buccal mucosa as graft material. The buccal mucosal wound completely healed 2 weeks after the operation and the neovaginal length and calibre were well formed. Follow-up ranged from 0.5 to 1.5 years. One patient encountered post-operative vaginal bleeding and another patient suffered from urinary bladder injury. CONCLUSION: This is the first reported procedure of vaginoplasty with autologous buccal mucosa as graft material. Our method is ideal in its simplicity, provides good cosmetic results, and improves the vaginal length of the patient.

Adult↗
PubMed2003

Anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty in women with Rokitansky's syndrome.

BACKGROUND: The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare congenital cause of primary amenorrhea, due to utero-vaginal agenesis. Several surgical techniques have been used to create a neovagina. Neovagina construction with a sigmoid graft appears to be the best option, as it offers adequate length and natural lubrication, allowing early intercourse. However, few data are available on the complications, anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty. METHODS: From September 1995 to November 2002, seven women with the MRKH syndrome underwent laparoscopic-perineal neovagina construction by sigmoid grafting. RESULTS: The mean operating time was 312 min (range 220-450 min). The mean fall in haemoglobin was 3.6 g/dl (range 2-4.4 g/dl). Blood transfusion was never necessary. The only perioperative complications were one urinary tract infection and one vulvar haematoma not requiring drainage. The mean hospital stay was 7.7 days (range 6-12 days). The mean length of the neovagina was 11.5 cm (range 7-15 cm), and no shrinkage occurred during follow-up. The neovaginal introitus admitted two fingers in breadth in five of the seven patients. Dilation of the introitus was required in the other two women. None of the four women who had intercourse experienced dyspareunia or discomfort. CONCLUSION: Our results confirm the feasibility of laparoscopic-perineal neovagina construction by sigmoid colpoplasty, when performed by surgeons with extensive experience in both gynaecological and gastrointestinal laparoscopic surgery. The anatomic and functional results were good.

Abnormalities, Multiple↗
PubMed2004

Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome.

Vaginal agenesis is an uncommon, but not rare, condition. Although there are many methods for creating a neovagina, the optimal treatment is unknown. An 18-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome received vaginoplasty with a modified Wharton procedure using an artificial dermis (atelocollagen sponge). From 10 days after the operation, the patient was administered human recombinant basic fibroblast growth factor (bFGF) spray to accelerate epithelialization on the neovagina. At 50 days after the operation, we confirmed histological squamous epithelialization of the vaginal epithelium. At 12 months after the operation, the neovagina was at least 3.5 cm in width and approximately 8 cm in length. In this case, use of artificial dermis and recombinant bFGF to create a neovagina was an easy, less invasive and useful method.

Abnormalities, Multiple↗
PubMed2005

Sexuality after laparoscopic Davydov in patients affected by congenital complete vaginal agenesis associated with uterine agenesis or hypoplasia.

BACKGROUND: Several surgical techniques have been described for the treatment of patients with vaginal agenesis. The simplest intervention that gives good sexual results should be the surgical technique of choice. METHODS: We report anatomic and functional outcome in 28 women after vaginoplasty using laparoscopic Davydov operation. This surgery includes three steps: two laparoscopic and one perineal. The patient then has to use a mould or a vaginal dilatator for 1 month. The functional outcome was assessed by a brief and valid self-report questionnaire evaluating female sexual life (Female Sexual Function Index, FSFI). A control group was recruited to compare the results. RESULTS: Two intra-operative bladder and ureteric injuries were repaired without sequels. Two post-operative complications were observed: one abdominal migration of the mould, which was treated successfully with the laparoscope, and one vesico-vaginal fistula. No patient was lost to follow-up. The anatomical result was judged to be satisfactory (>6 cm) in 26 of the 28 patients: the mean vaginal length was 7.2 +/- 1.5 cm. Among the 28 operated women, 19 had a good or very good result. No statistical difference was found between our operated patients and French controls in all six domains of the FSFI. CONCLUSIONS: Laparoscopic Davydov may be considered a good option for the surgical treatment of women presenting vaginal agenesis. This technique offers advantages such as: short operating time and hospital stay, no particular instrumentation required and no external scars. Sexuality approaches so-called 'normal sexuality'.

Abnormalities, Multiple↗
PubMed2006

Laparoscopic creation of a neovagina and recovery of menstrual function in a patient with Rokitansky syndrome: a case report.

A 16-year-old woman experiencing primary amenorrhoea and cyclic pelvic pain was diagnosed with Rokitansky syndrome, which was characterized by the absence of the uterus and the upper two-thirds of the vagina, normal salpinges and ovaries and a 4 x 3 cm Müllerian remnant containing functioning endometrium located near the left adnexa. With a combined laparoscopic-vaginal operation, the remnant was anastomized with the apex of the retrohymenal fovea. The operation allowed not only the creation of a neovagina but also the recovery of a regular menstrual activity and the theoretical restoration of the reproductive capacity of this patient. An accurate pre- and intra-operative evaluation of patients with Rokitansky syndrome is necessary to identify those who might benefit from this procedure.

Adolescent↗