The Donut DIEP Flap: A Novel Scarless Technique.

Deep inferior epigastric perforator (DIEP) flap surgery is a common technique for breast reconstruction. However, the long and noticeable abdominal scarring is one of its greatest disadvantages. Here, we suggest a minimal scarring DIEP flap harvest with a novel abdominal design. The key to this method is to preserve more skin tissue with a circular design centered around the navel. Three circular incisions are made: (1) the smallest circle represents an incision around the umbilicus; (2) the middle circle with a radius of <3.5 cm indicates skin incision because the donut-like skin paddle between the small and middle circles is included in the flap; (3) the largest circle with a radius of >10 cm represents the extent of flap dissection that was done diagonally from the skin toward the Scarpa's fascia. Pedicle dissection is proceeded with the conventional method. For closure, a purse-string suture is performed with the umbilicus at its center leaving only a single small circular scar around the umbilicus as the final scar. Closure of the donor-site is possible with the patient in a supine or slightly flexed position due to less skin excision. LEVEL OF EVIDENCE: Therapeutic, V.

Prophylactic intraoperative wound irrigation with antibiotic solution for the prevention of surgical incisional wound infections: Systematic literature review and meta-analysis.

BACKGROUND: There is no consensus on the use of prophylactic intraoperative wound irrigation (pIOWI) for reducing surgical-site infections (SSIs), particularly surgical incisional wounds, and opinions are divided on whether an antibiotic should be mixed with the solution used for incisional wound irrigation. No large, reliable cohort studies or meta-analyses of pIOWI for surgical incisional wounds were found in PubMed or Embase. METHODS: We searched the PubMed, Embase, Cochrane Library, Insight, Scopus, and Web of Science databases for primary research articles investigating the relevance of pIOWI with antibiotics for SSIs. The initial search was limited to human studies published before January 2022, which were indexed as randomized controlled trials (RCTs); clinical trials; or observational, cross-sectional, or cohort studies. We used R statistical software version 4.1.2 for this meta-analysis. RESULTS: The odds ratio of the random-effects model was 0.519 [95% confidence interval (CI); 0.311, 0.864, P-value < 0.0117], indicating that the intervention had a statistically significant effect on surgical complications. To examine the heterogeneity of the entire study, we performed statistical analysis (τ2 (tau square) = 0.4175 [0.0732; 2.8178]; τ (tau) = 0.6461 [0.2706; 1.6786]; Higgins' I2 = 64.0% [34.8%; 80.1%]; and H = 1.67 [1.24; 2.24]). CONCLUSIONS: Many studies have shown that inclusion of antibiotics in the irrigation solution significantly lowers the rate of soft-tissue-related SSIs, but those studies contain both heterogeneity and many biases. Further large, prospective RCTs only limited to incisional SSIs and excluding other variables and biases in the field of plastic surgery are needed.

Late reconstruction of post-traumatic enophthalmos and hypoglobus using three-dimensional implants: a case series.

Post-traumatic enophthalmos and hypoglobus are common sequelae of facial bone fractures, even after reduction surgery. They are associated with functional and esthetic issues, which may lower the quality of life. These deformities frequently present late, and adequate correction is difficult. We report three cases of late inferior orbital rim reconstructions with three-dimensional printed implants to help resolve these problems. The average duration between the traumatic event and surgery was 3 years and 4 months. One patient was treated with a completely absorbable implant and exhibited satisfactory results until the implant started to biodegrade at 1 year and 9 months after surgery. Two patients were treated with a permanent implant and demonstrated satisfactory results. However, longer follow-up periods were needed. There were no complications such as infection, diplopia, or restriction of ocular motion and the patients were satisfied with the esthetic results.

Cranioplasty and temporal hollowing correction with a three-dimensional printed bioresorbable mesh and double vertical suture anchor muscle sling: a case report.

Postoperative temporal hollowing is a common complication of craniotomy. Damage and repositioning of the temporalis muscle can lead to a depression in the temporal side of the skull with inferior bulging, worsening aesthetic outcomes. We report a case of cranioplasty with three-dimensional (3D) printed mesh involving an additional correction using a temporalis muscle sling to help address this problem. A 3D-printed bioabsorbable mesh was prepared based on preoperative facial computed tomography, and was fixed to the hollowed area for tissue augmentation. The temporalis muscle was elevated and fanned out to its original position, and a sling was attached to a screw that was fixed to the mesh. For reinforcement, an additional sling was attached to another screw fixed to the mesh 2-3 cm vertically above the first screw. Aesthetic results were confirmed immediately after surgery and later during outpatient follow-up. Both depression and lateral bulging were resolved, and there was no delayed drooping of the temporalis muscle on 6-month follow-up. There were no complications, and the patient was satisfied with the appearance. This is a simple yet effective technique with a low risk of complications, and should be considered for postoperative temporal hollowing patients, especially those with severe lateral bulging.

Hydrogel Stamping for Rapid, Multiplexed, Point-of-Care Immunostaining of Cells and Tissues.

In the era of precision oncology, multicolor fluorescence imaging has become a core technology for multiplexed molecular analysis of cellular and tissue specimens. However, conventional solution-based staining is labor-intensive and time-consuming and requires considerable expertise to yield optimal results, which creates difficulties for employing this technology in resource-limited settings. Here, we report a new immunostaining method based on hydrogel stamping, which is simple, fast, easy to use, and reproducible. We showed that a hydrophilic hydrogel stamp could effectively transfer fluorescent antibodies to targets and withdraw an excess solution when the reaction is completed, obviating the need for extra washing. This unique property allows for quality immunostaining in 5 min for cells using one-eighth of antibody consumption compared to the conventional solution-based method. Furthermore, we implemented fluorescence quenching and immunocycling with hydrogel staining for multiplexed analysis of 9 protein markers at a single cell level. Finally, we applied the immunocycling method to human breast cancer tissue samples and showed quality immunostaining over a large area (∼2 cm2) in 30 min for molecular subtyping of breast cancer. The hydrogel immunostaining could open new opportunities for rapid, automated, and multiplexed profiling in compact point-of-care systems for molecular cancer diagnosis.

Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System.

SUMMARY: Deep inferior epigastric artery perforator (DIEP) flap surgery is one of the most common techniques for breast reconstruction using abdominal tissue. Although the DIEP flap reduces donor-site morbidity when compared with the conventional free transverse rectus abdominis musculocutaneous flap, violation of the anterior rectus sheath, rectus muscle, and motor nerves cannot be avoided. To further minimize tissue damage in the donor site, the use of a surgical robotic system for DIEP flap harvest with a totally extraperitoneal approach has been suggested. This totally extraperitoneal approach has a long learning curve because of the narrow preperitoneal space and the difficulty of converting a potential space to an actual space. Thus, the authors suggest a single-port robotic system optimized for narrow surgical spaces as a feasible option for DIEP flap harvest by a totally extraperitoneal approach, which has a shorter learning curve.

Epigenetic regulation of mammalian Hedgehog signaling to the stroma determines the molecular subtype of bladder cancer.

In bladder, loss of mammalian Sonic Hedgehog (Shh) accompanies progression to invasive urothelial carcinoma, but the molecular mechanisms underlying this cancer-initiating event are poorly defined. Here, we show that loss of Shh results from hypermethylation of the CpG shore of the Shh gene, and that inhibition of DNA methylation increases Shh expression to halt the initiation of murine urothelial carcinoma at the early stage of progression. In full-fledged tumors, pharmacologic augmentation of Hedgehog (Hh) pathway activity impedes tumor growth, and this cancer-restraining effect of Hh signaling is mediated by the stromal response to Shh signals, which stimulates subtype conversion of basal to luminal-like urothelial carcinoma. Our findings thus provide a basis to develop subtype-specific strategies for the management of human bladder cancer.

A universal ultrasound diagnostic system developed to support urology and coloproctological applications.

In this study, we sought to describe a novel imaging apparatus that is lightweight, inexpensive, and highly effective for use in colorectal diagnostic and treatment settings. Typical probes for use in colorectal ultrasonic imaging applications are developed for surgeons to diagnose and stage rectal tumors and image the rectum and anus. Here we outline a new technique and use it for colorectal imaging in an animal. This technique involves use of an ultrasound array module positioned along the axis of rotation such that improved rotation is possible. This module is in the shape of a linear rod with a rotary linear component that allows for emission of focused ultrasonic echo signals from a linear section of the probe. The usability of the transducer and rectal image quality are satisfactory in a porcine model with the technique proposed here, axial/lateral resolution as 0.96/2.24 mm with 6 dB applied through the contour map using the point spread function. When compared to currently available methods, this technique provides superior diagnostic 3D volumetric image quality with reduced acquisition time. Given this, the ultrasound device proposed here may prove a viable and preferable method to those currently available for urology and colorectal imaging applications.

Neuroprotective and antioxidant activities of bamboo salt soy sauce against H2O2-induced oxidative stress in rat cortical neurons.

Bamboo salt (BS) and soy sauce (SS) are traditional foods in Asia, which contain antioxidants that have cytoprotective effects on the body. The majority of SS products contain high levels of common salt, consumption of which has been associated with numerous detrimental effects on the body. However, BS may be considered a healthier substitute to common salt. The present study hypothesized that SS made from BS, known as bamboo salt soy sauce (BSSS), may possess enhanced cytoprotective properties; this was evaluated using a hydrogen peroxide (H2O2)-induced neuronal cell death rat model. Rat neuronal cells were pretreated with various concentrations (0.001, 0.01, 0.1, 1 and 10%) of BSSS, traditional soy sauce (TRSS) and brewed soy sauce (BRSS), and were subsequently exposed to H2O2 (100 µM). The viability of neuronal cells, and the occurrence of DNA fragmentation, was subsequently examined. Pretreatment of neuronal cells with TRSS and BRSS reduced cell viability in a concentration-dependent manner, whereas neuronal cells pretreated with BSSS exhibited increased cell viability, as compared with non-treated neuronal cells. Furthermore, neuronal cells pretreated with 0.01% BSSS exhibited the greatest increase in viability. Exposure of neuronal cells to H2O2 significantly increased the levels of reactive oxygen species (ROS), B-cell lymphoma 2-associated X protein, poly (ADP-ribose), cleaved poly (ADP-ribose) polymerase, cytochrome c, apoptosis-inducing factor, cleaved caspase-9 and cleaved caspase-3, in all cases. Pretreatment of neuronal cells with BSSS significantly reduced the levels of ROS generated by H2O2, and increased the levels of phosphorylated AKT and phosphorylated glycogen synthase kinase-3ß. Furthermore, the observed effects of BSSS could be blocked by administration of 10 µM LY294002, a phosphatidylinositol 3-kinase inhibitor. The results of the present study suggested that BSSS may exert positive neuroprotective effects against H2O2-induced cell death by reducing oxidative stress, enhancing survival signaling, and inhibiting death signals.

Comparison of computed tomography findings between renal oncocytomas and chromophobe renal cell carcinomas.

PURPOSE: To investigate and distinguish the computed tomography (CT) characteristics of chromophobe renal cell carcinoma (chRCC) and renal oncocytoma. MATERIALS AND METHODS: Fifty-one patients with renal oncocytoma and 120 patients with chRCC, diagnosed by surgery between November 2005 and June 2015, were studied retrospectively. Two observers, who were urologists and unaware of the pathological results, reviewed the preoperative CT images. The tumors were evaluated for size, laterality, tumor type (ball or bean pattern), central stellate scar, segmental enhancement inversion, and angular interface pattern and tumor complexity. To accurately analyze the mass-enhancing pattern of renal mass, we measured Hounsfield units (HUs) in each phase and analyzed the mean, maximum, and minimum HU values and standard deviations. RESULTS: There were 51 renal oncocytomas and 120 chRCCs in the study cohort. No differences in clinical and demographic characteristics were observed between the two groups. A central stellate scar and segmental enhancement inversion were more likely in oncocytomas. However, there were no differences in ball-/bean-type categorization, enhancement pattern, and the shape of the interface between the groups. Higher HU values tended to be present in the corticomedullary and nephrogenic phases in oncocytomas than in chRCC. Receiver-operating characteristic curve analysis showed that the presence of a central stellate scar and higher mean HU values in the nephrogenic phase were highly predictive of renal oncocytoma (area under the curve=0.817, p<0.001). CONCLUSIONS: The appearance of a central stellate scar and higher mean HU values in the nephrogenic phase could be useful to distinguish renal oncocytomas from chRCCs.

Peptide-induced formation of a tethered lipid bilayer membrane on mesoporous silica.

Tethered bilayer lipid membranes (tBLMs) on solid supports have substantial advantages as models of artificial cell membranes for such biomedical applications as drug delivery and biosensing. Compared with untethered lipid membranes, tBLMs have more space between substrate and the bilayer and greater stability. The purpose of this work was to use these properties to fabricate and characterize a zwitterionic 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine lipid tBLM containing 2 mol% 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-maleimide(poly(ethylene glycol))-2000 (DSPE-PEG2000-NHS) lipid tethers on a 3-aminopropyltrimethoxysilane-modified mesoporous silica substrate. A quartz crystal microbalance with dissipation monitoring was used to monitor the process of vesicle adsorption and tBLM self-assembly, and atomic force microscopy was performed to characterize the structural properties of the tBLM obtained. Whereas tether-containing lipid vesicles ruptured neither spontaneously nor as a result of osmotic shock, introduction of an amphipathic α-helical (AH) peptide induced vesicle rupture and subsequent tBLM formation. Taken together, our findings suggest that the AH peptide is an efficient means of rupturing vesicles of both simple and complex composition, and is, therefore, useful for formation of tBLMs on solid and mesoporous materials for applications in biotechnology.

Preoperative urodynamic factors predicting outcome of botulinum toxin-A intradetrusor injection in children with neurogenic detrusor overactivity.

OBJECTIVE: To investigate urodynamic (UD) parameters that predict outcome of intradetrusor botulinum toxin-A (BTX-A) injection in children with neurogenic detrusor overactivity (NDO), by reviewing clinical and UD data. METHODS: From January 2010 to March 2014, 56 cases of the first BTX-A intradetrusor injection were performed in pediatric patients with NDO. We excluded 19 cases based on these criteria: patient age <4 years, no preoperative UD study or postoperative outcome assessment, and simultaneous sphincter injection. Based on the Patient Global Impression of Improvement, patients were classified as responders or nonresponders. RESULTS: Thirty-seven cases were included finally. Mean number of pads used per day was significantly decreased after BTX-A injection (2.67 ± 1.46 vs 1.37 ± 1.15; P <.001). On postoperative UD study, maximum cystometric capacity and residual urine volume were significantly increased above baseline. Persistent NDO was only detected in 3 cases (8.1%). Regardless of UD improvements, 20 cases were responders, whereas 17 were nonresponders based on Patient Global Impression of Improvement. Preoperative bladder compliance was significantly lower in nonresponders (25.11 ± 32.59 vs 8.64 ± 6.52; P = .039). Open bladder neck (OBN) was seen in 9 cases and more likely occurred in nonresponders. Regression analysis revealed that poor bladder compliance (<10 mL/cm H2O; odds ratio, 6.041; 95% confidence interval, 1.189-30.677; P = .030) and presence of OBN (odds ratio, 16.889; 95% confidence interval, 1.825-156.282; P = .031) were independent predictors of poor response after BTX-A injection. CONCLUSION: Preoperative bladder compliance and OBN were important predictors of outcome after BTX-A intradetrusor injection. Thus, intradetrusor BTX-A injection should be considered in select patients to achieve optimal outcome.

Feasibility and efficacy of intermediate-supine percutaneous nephrolithotomy: initial experience.

We evaluated the feasibility and efficacy of intermediate-supine percutaneous nephrolithotomy (PCNL) in patients with renal calculi. Fifteen patients were included in this study. The intermediate-supine operative position was modified by using a 1-L saline bag below the ipsilateral upper flank. A nephrostomy and stone extraction were performed as usual. After completion of the stone removal, a nephrostomy tube was used when necessary according to the surgeon's decision. If there was no significant bleeding or renal pelvic injury, tubeless PCNL was performed. The mean stone size was 5.48±5.69 cm(2), the mean operative time was 78.93±38.72 minutes, and the mean hospital stay was 2.60±1.29 days. Tubeless PCNL was performed in 13 cases (86.7%), and retrograde procedures were simultaneously performed without a change of position in 2 patients (ureteroscopic ureterolithotomy in one patient and transurethral placement of an occlusion catheter in one patient). There were two complications according to the Clavien-Dindo classification (Grade I in one patient and Grade II in one patient). The success rate was 80.0% and the complete stone-free rate was 73.3%. Three patients with a significant remnant stone were also successfully managed with additional procedures (one patient underwent a second-look operation, and the remaining two patients were treated with shock wave lithotripsy). In the treatment of renal calculi, intermediate-supine PCNL may be a safe and effective choice that offers several advantages with excellent outcomes. Thus, a prospective study with a larger population is needed to verify our outcomes.

Bimodal tumor-targeting from microenvironment responsive hyaluronan layer-by-layer (LbL) nanoparticles.

Active targeting of nanoscale drug carriers can improve tumor-specific delivery; however, cellular heterogeneity both within and among tumor sites is a fundamental barrier to their success. Here, we describe a tumor microenvironment-responsive layer-by-layer (LbL) polymer drug carrier that actively targets tumors based on two independent mechanisms: pH-dependent cellular uptake at hypoxic tumor pH and hyaluronan-directed targeting of cell-surface CD44 receptor, a well-characterized biomarker for breast and ovarian cancer stem cells. Hypoxic pH-induced structural reorganization of hyaluronan-LbL nanoparticles was a direct result of the nature of the LbL electrostatic complex, and led to targeted cellular delivery in vitro and in vivo, with effective tumor penetration and uptake. The nanoscale drug carriers selectively bound CD44 and diminished cancer cell migration in vitro, while co-localizing with the CD44 receptor in vivo. Multimodal targeting of LbL nanoparticles is a powerful strategy for tumor-specific cancer diagnostics and therapy that can be accomplished using a single bilayer of polyamine and hyaluronan that, when assembled, produce a dynamic and responsive cell-particle interface.