Knowledge and Attitude about Labor Epidural Analgesia among Pregnant Women Attending Antenatal Clinic.

BACKGROUND: Labour pain is one of the most painful experiences that a woman faces in her lifetime. There are various options for labour pain management. Epidural analgesia is the gold standard method for pain management during labour. In developing and under-developed countries there are many challenges to provide this service, a very important one being knowledge about epidural analgesia among the parturients and the physicians. METHODS: A prospective cross-sectional study was carried out among 384 pregnant women attending Antenatal clinic of a tertiary level teaching hospital using pretested structured questionnaire prepared by a team of anaesthesiologists and obstetricians. Non-probability purposive sampling technique was used. The data was analysed by using SPSS version 20.0. Descriptive and inferential statistical methods were used for analysis. RESULTS: Of the 384 pregnant women, only 29.4% had knowledge about some form of labour analgesia techniques and only 16% of the participants were aware of labour epidural analgesia. Also, only 6.2% were aware that epidural service is available at our hospital. Regarding acceptance, only 42.4% were willing to use epidural analgesia in their present pregnancy. CONCLUSIONS: The present study findings revealed that a significant number of participants had very limited knowledge about labour epidural analgesia and were also unaware of the availability of the service in our hospital. Educational programs need to be provided to all the pregnant women for enhancement of knowledge and awareness about epidural labour analgesia to increase its acceptability among them.

Predictors of elaborated perineal or a combined abdominoperineal approach during repair for pelvic fracture urethral injury.

PURPOSE: A step-based anastomotic urethroplasty is a standard technique for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). We aim to identify pre-operative factors, including results of conventional radiological imaging, for prediction of elaborated perineal or a combined abdominoperineal procedure. METHODS: Retrospective observational study on 114 consecutive patients undergoing urethroplasty for PFUI between January 2020 and December 2022 was conducted. Surgical procedures were categorized according to the Webster classification into two groups: steps 1-2 (group 1) and steps 3-4 or a combined abdominoperineal repair (group 2). Pre-operative pattern results of RGU/VCUG were categorized regarding the relation between the proximal urethral stump with the pubic symphysis: posterior urethral stump below (pattern 1) or above (pattern 2) the lower margin of the pubic symphysis. Patient demographics were assessed. Univariate and multivariate logistic regression analyses were utilized. RESULTS: Overall, 102 patients were enrolled in the study for data analysis. On the multivariate logistic regression analysis, the presence of erectile dysfunction (OR 4.5; p = 0.014), prior combined treatment (endoscopic and urethroplasty) (OR 6.4; p = 0.018) and RGU/VCUG pattern 2 (OR 66; p < 0.001) significantly increased the likelihood of the need of step 3 or higher. CONCLUSIONS: The need of step 3 or higher during urethroplasty for PFUI can be predicted pre-operatively with conventional imaging (RGU/VCUG). Patients with proximal urethral stump above the lower margin of pubic symphysis were about 66 times more likely to need step 3 or higher during urethroplasty.

Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique.

PURPOSE: To report the 12-month results of a novel urethroplasty technique relying on a spiral preputial graft for panurethral stricture disease. MATERIALS AND METHODS: Twenty consecutive patients were treated between May and October 2021 at our center. A spiral preputial mucocutaneous graft is a foreskin-based graft, developed from a 5-cm-wide preputial skin, which is harvested using a helicoidal shape and can reach up to 20 cm in length. Stricture characteristics were assessed through preoperative retrograde and voiding cystourethrogram and maximum uroflowmetry data (Qmax). Complications were collected up to 30 days after surgery and graded using the Clavien-Dindo (C-D) classification. The patients were followed up to 12 months. RESULTS: Preoperative median Qmax was 6.5 ml/s [interquartile range (IQR): 4.0-8.7]. After a median follow-up of 12 months (IQR 12-13), six patients experienced at least one complication. Of them, two patients had grade 2 C-D complications, while only one developed a grade 3a C-D complication. The median postoperative Qmax was 16 ml/s (IQR: 13-18). Only one patient had early urethral stricture recurrence treated with dilatation after catheter removal. At one-year follow-up, no other patients had urethral stricture recurrence with an overall median Qmax of 15.1 ml/s (IQR 13.5-16.4). CONCLUSIONS: Our novel single-stage spiral preputial graft urethroplasty for panurethral stricture treatment appears to be safe and could be used as a valid alternative to two-stage procedures or even to single-stage buccal mucosa graft augmentation.

Management of Pelvic Fracture Urethral Injury: Is Supracrural Urethral Rerouting (Step 4) Becoming Anecdotical or Does It Remain in Force?

Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. We evaluated the outcomes of anastomotic urethroplasty (especially Step 4 or higher) or substitution urethroplasty in patients with PFUI at our center. Between 2013 to 2021, we retrospectively collected data on patients with PFUI. Surgical procedures were categorized according to the Webster classification and rates of each step were reported. The success rate was defined as Qmax above 10 mL/s and no need for further treatment. In this period, 737 male patients with PFUI were surgically treated. Notably, 18.8%, 17.6%, 46%, 1.8%, and 5.6% of included patients received steps 1, 2, 3, and 4 and the abdominoperineal approach, respectively. In 68 (9.2%) patients, the substitution of urethroplasty with a pedicled preputial tube (PPT) was needed. The success rate was 69.2% in Step 4, 74.4% in the abdominoperineal approach, and 86.4% in PPT; however, recurrence-free survival was not significantly different between groups (p = 0.22). Step 4 perineal anastomotic urethroplasty represents a surgical option in the armamentarium of PFUI treatment. Indications should be carefully reviewed to improve patient selection and avoid surgical failure, stopping at the step which first gives a tension-free anastomosis.

Anaesthetic Management of a Patient with Fontan Circulation for Laparoscopic Cholecystectomy.

Fontan circulation is a complex surgical procedure carried out in infants in a staged fashion, where caval circulation is connected to the pulmonary circulation, bypassing the heart. The ventricular activity will drive the blood to pulmonary circulation, which, after oxygenation, will return to heart and then will distribute through-out the body. The pulmonary vascular resistance determines the preload, which further depends upon the volume status of the body. This physiology is further complicated by the presence of arrythmia, liver cirrhosis, caval-pulmonary shunt thrombosis and low ventricular activity. Anaesthetic implication of such case includes challenges to manage preload, maintenance of pulmonary vascular resistance, preservation of the single ventricular function and avoidance of circuit thrombosis. Here we present a case of 15 years female who presented to our centre for laparoscopic cholecystectomy. Keywords: Cholecystectomy; Circulation; Laparoscopic.

Advances in urethroplasty.

There has been rapid evolution in management of urethral strictures in the last 3 decades. From the era of dilatation, we have moved to urethral reconstruction. Reinvention of buccal grafts changed the outcomes of urethroplasty. Barbaglis dorsal onlay popularised stricture management across the globe. Kulkarni described a single stage surgery for panurethral stricture. Advances have taken place, and we have moved from transecting to the non-transecting approaches. We describe the various advances in urethral reconstruction in the last decade.

The impact of surgical volume on perioperative safety after urethroplasty: a population-based study.

BACKGROUND: The aim of the study was to assess whether the risk of perioperative complications after urethroplasty was affected by hospital annual surgical volume (ASV). METHODS: In the Nationwide Inpatient Sample, we searched for patients who underwent urethroplasty between 2001 and 2015. Hospitals were categorized into empirically determined tertiles, according to ASV of performed urethroplasties and divided into low (<3) (LVC), intermediate (3-19) (IVC) and high (>20) volume centers (HVC). Multivariable logistic regression (MLR) analyses examined the effect of ASV on perioperative complications and on four specific sub-types of post-operative complications. RESULTS: A weighted estimate of 39 912 patients underwent urethroplasty in the US. 34.9% were operated in HVC, while the rate of performed urethroplasties increased in LVC and decreased in HVC. Overall, 1.1%, 18.8% and 2.1% patients respectively experienced intraoperative, post-operative, and transfusions complications. At MLR, IVC and LVC were associated with higher risk of both intraoperative (IVC: OR 2.65, P=0.0008; LVC: OR 4.98, P<0.0001), post-operative (IVC: OR 1.14, P=0.01; LVC: OR 1.26, P=0.001) and transfusions complications (IVC: OR 1.85, P<0.001; LVC: OR 3.03, P=0.01). LVC was also associated with higher risk of hematuria (OR 3.77), urinary infections (OR 1.60) and sepsis (OR 2.83) complications. CONCLUSIONS: Approximately 65% of patients were operated in IVC and LVC, and patients treated in IVC or LVC had higher risk of developing both intra and post-operative complications. These data provide important indicators for policy makers to categorize institution based on urethroplasty outcomes.

How to do a penile urethroplasty using a novel self-retaining penile retractor.

Effective retraction and clear exposure of urethral tissue is essential in reconstructive penile surgery. The Joshi-Kulkarni retractor provides stable, bloodless operative exposure via non-traumatic tissue compression at the base of penis. The self-retaining design of this retractor also improves ergonomics thereby reducing surgeon fatigue. In this article, we describe how to do a penile urethroplasty by using the Joshi-Kulkarni penile retractor.

Common Flaps in Genitourinary Reconstruction.

Urethroplasty has evolved over time. The twentieth century saw management of urethral strictures and hypospadias with flaps. Things changed in the late 1990s with reintroduction of grafts. Buccal mucosa grafts gained popularity. There are failed urethroplasties and obliterative strictures, mostly iatrogenic, after urologic endosurgery. Such strictures need vascularized augmentation or substitution with flaps. Reconstructive urologists should be well versed in management of all types of complex cases. This article discusses the commonly used flaps in genitourinary reconstruction. Penile flaps are the commonest. Overall, the winner is the dartos. All penile flaps are based on the excellent vascularity of dartos.

Which Are the Commonest Sites and Characteristics of Post-Transurethral Prostate Surgery Strictures in a High-Volume Reconstructive Center?

Background: Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center. Methods: We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017 to 2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture. Results: Median stricture length was 5 cm (4-7). One hundred forty-one (70.1%) patients received previous no-invasive treatments (dilatation and/or direct visual internal urethrotomy). Proximal bulbar urethra was the commonest site for stricture, whereas panurethral stricture (≥10 cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared with patients with other involved segments (26% vs 19%, p = 0.03), and it was the only predictor of penile and midbulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naive, p = 0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), whereas ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approaches in membranous strictures. Conclusions: Most patients who were referred for TPS-induced stricture attempted previous noninvasive managements. Referred TPS-induced urethral strictures were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach because of the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in a specific segment of urethra, namely the penile and midbulbar urethra.

Mucosal-sparing augmented non-transected anastomotic (MsANTA) urethroplasty: a step forward in ANTA urethroplasty.

The surgical advancement of urethral reconstruction is a rapidly moving field. In the last decade, the technique for bulbar urethroplasty has evolved towards less invasive approaches with minimal transection and more tissue sparing in order to increase the patency rate. In this study, we provide a step forward in the augmented non-transected anastomotic (ANTA) urethroplasty proposed in 2012, with a true mucosa-sparing modification of the technique. In detail, the bulbar urethral lumen is approached with either a ventral or dorsal urethrotomy. Differently from previous techniques, the native urethral mucosa is neither transected nor resected but is reconstructed with a direct mucosa-to-mucosa anastomosis. This allows a complete sparing of communicant vessels that come from the corpus spongiosum to the urethral mucosa. The technique aims to preserve the native vascularity of the urethral mucosa by enlarging the native urethral plate with a direct anastomosis at the level of the stricture, and without the need for resection. In our hands the technique was easy and reproducible, and it carried promising results in the preliminary cohort where it was applied.

Long-term outcomes from a multi-institutional experience with prefabricated composite gracilis-buccal mucosal flap for reconstruction of devastated urethras.

PURPOSE: Patients with devastated bulbar urethras have limited surgical options to restore normal upright voiding. We investigated the long-term feasibility of using two independently vascularized urethral hemi-plates lined with buccal mucosal graft (BMG) to treat these patients. METHODS: A multi-institutional retrospective review was conducted for patients that underwent this staged repair. In stage-1, the affected urethra is dissected and removed or prepared for a dorsal inlay augmentation. Two BMG segments are harvested; one graft is quilted on corpora cavernosa and urethra, creating an augmented perineal urethrostomy, and the other is quilted on the exposed distal gracilis muscle. Stage-2 utilizes the gracilis-BMG composite to recreate ventral bulbar urethra. The primary outcome measure was stricture recurrence. Secondary outcome measures included patient-reported outcome measures (PROMs). RESULTS: Five patients with mean age of 50 years (45-56) underwent staged repairs at two institutions between 7/2014 and 4/2016. All patients presented with suprapubic tubes and underwent at least one prior failed repair (1-9). Mean stricture length was 7.2 cm (5-9). Mean time between stage-1 and stage-2 repairs was 6.2 weeks (1-10). At a mean follow-up of 61 months (39-87), there were no recurrences. The mean uroflow was 20 cc/s (9-42) with a mean PVR of 59 cc (0-157). Four patients completed post-operative surveys; all reported at least a moderate improvement in their condition on Global Response Assessment (GRA), and a mean IPSS of 7.3 (0-26). CONCLUSIONS: Our bi-institutional case series demonstrates that this technique is a feasible option for devastated urethras with long-term durability.

Dorsal approach for double-face bulbar urethroplasty: ventral inlay plus dorsal onlay using Kulkarni one-side dissection.

BACKGROUND: Non-traumatic obliterative bulbar urethral stricture with residual urethral lumen below 3 Fr is a challenging surgical scenario for reconstructive surgeons, because either anastomotic or single augmentation urethroplasty is not an option. OBJECTIVES: To describe our double-face buccal mucosa graft (BMG) urethroplasty with dorsal onlay and ventral inlay relying on the vessels and nerve-sparing technique of Kulkarni's one-side dissection. METHODS: We retrospectively reviewed a prospectively maintained database of patients with non-traumatic obliterative bulbar urethral strictures who underwent double-face bulbar urethroplasty with one-side dissection and dorsal onlay plus ventral inlay BMG. Patient demographics, clinical data, and follow-up were analyzed. RESULTS: A total of 59 patients underwent double-face urethroplasty with dorsal approach. The median age was 37 years (IQR 27-49) and the median stricture length was 5 cm (IQR 3.75-6). No patients had immediate post-operative complications. The overall success rate was 88% with a median follow-up of 30.9 months (IQR 16.9-44.2). Two patients were treated with DVIU, and two patients with open urethral surgery. One patient developed erectile dysfunction after surgery. Age, etiology, stenosis length and previous treatment were not factors related to surgical failure. CONCLUSION: Our preliminary albeit encouraging results showed that this approach was feasible in all patients and with negligible perioperative complications. Success rate was 88%. We did not find any factors related to surgical failure. Our dorsal double-face augmented urethroplasty may be a valid alternative to the Palminteri's ventral double-face urethroplasty, especially in those patients with mid-distal bulbar or peno-bulbar urethral strictures.

Physicochemical and biological analysis of river Yamuna at Palla station from 2009 to 2019.

Yamuna is one of the main tributaries of the river Ganga and passes through Delhi, the national capital of India. In the last few years, it is considered one of the most polluted rivers of India. We carried out the analysis for the physiochemical and biological conditions of the river Yamuna based on measurements acquired at Palla station, Delhi during 2009-19. For our analysis, we considered various physicochemical and biological parameters (Dissolved Oxygen (DO) Saturation, Biological Oxygen Demand (BOD), Chemical Oxygen Demand (COD), Total Alkalinity, Total Dissolved Solids (TDS), and Total Coliform. The water stats of river Yamuna at Palla station were matched with Water Standards of India, United Nations Economic Commission for Europe (UNECE), and World Health Organization (WHO). Maximum changes are observed in DO saturation and total coliform, while BOD and COD values are also seen higher than the upper limits. Total alkalinity rarely meets the minimum standards. TDS is found to be satisfactory as per the standard limit. The river quality falls under Class D or E (IS2296), Class III or IV (UNECE), and fails to fulfill WHO standards for water. After spending more than 130 million USD for the establishment of a large number of effluent treatment plants, sewage treatment plants, and common effluent treatment plants, increasing discharges of untreated sewage, partially treated industrial effluents and reduced discharge of freshwater from Hathnikund are causing deterioration in water quality and no major improvements are seen in water quality of river Yamuna.

Comprehensive analysis of paediatric pelvic fracture urethral injury: a reconstructive centre experience.

OBJECTIVE: To analyse our experience in pelvic fracture urethral injury (PFUI) in children and adolescents, with various anastomotic urethroplasties (AUs) used to accomplish tension-free anastomosis described and their surgical outcomes evaluated. PATIENTS AND METHODS: From 2008 to 2019, 192 cases including both primary and redo PFUI, which comprised 181 boys and 11 girls aged ≤18 years. The results are presented separately according to gender. Moreover, the two populations were divided in two age-related sub-groups for sensitivity analyses: Group 1 (children) aged ≤11 years and Group 2 (adolescent) aged 12-≤18 years. RESULTS: The median (interquartile range [IQR]) age at presentation in our series was 14 (9-17) years for boys and 9 (6-10) years for girls. Primary vs redo cases were 85 (47%) vs 96 (53%) in boys and 10/11 vs one of 11 in girls. In the primary male cases (85), the bulbo-membranous junction was the commonest site of injury (63, 74.1%). In boys, transperineal AU (TPAU) was performed in 160 (88.4%) and transpubic urethroplasty (TPU) in 17 (9.4%). In girls, TPU was utilised in nine cases, where two received meatoplasty and vaginal episiotomy. In boys, the overall success rate for TPAU was 81.2% and in primary PFUI cases success for TPAU was 88.3%. Overall success for TPU was 64.7%. In girls, the success rate for TPU was 100%. In boys and girls, the success rates for various AUs utilised between the child and adolescent groups were comparable. The median (IQR) hospital stay was 3 (3-4) days for boys and girls. The median (IQR) follow-up duration was 25 (16-33) months and 20 (17-27) months for boys and girls, respectively. Secondary procedures were performed in 39 boys and one girl, which comprised laser optical internal urethrotomy in 26 (14.4%) boys and redo surgery in 13 (7.2%) boys and one (9.1%) girl. Of all patients, four of the 11 girls and 74 boys (38.5%) were lost to follow-up. CONCLUSIONS: Most paediatric PFUI can be addressed via a transperineal approach with reasonable long-term outcomes. In challenging cases salvage procedures utilising vascular-based flaps as a urethral substitute give satisfactory results. Even young children can be managed with a high success rate in expert hands and these injuries should be addressed by specialist reconstructive urologists.