Bilateral urinary calculi with discordant stone composition.

OBJECTIVES: To describe a cohort of bilateral stone formers with significantly different compositions between renal units. METHODS: Patients treated for bilateral nephrolithiasis over a 4-year period (2007-2010) were identified. Stones were categorized by dominant (≥50%) mineralogical component. Patients with significant compositional differences between renal units (discordant stone formers) were compared to patients with a similar stone type in each kidney. RESULTS: Fifteen of the 59 bilateral stone formers (25.4%) were discordant stone formers with significant differences in stone composition between renal units. Forty-four of the 59 patients (74.6%) had the same stone composition on each side. Thirty percent of discordant stones had calcium phosphate as the dominant stone component. Discordant stone formers were younger, had better renal function, and tended to have a larger stone burden (p < 0.05). CONCLUSIONS: A significant minority of bilateral stone formers form a different type of stone in each kidney. Local or micro-environmental etiologies may explain this phenomenon and may also account for failure of preventive therapy in some patients.

Increasing Pedicle Reach with Musculocutaneous Perforator Dissection in Anterolateral Thigh Free Flaps.

OBJECTIVE: To measure the increase in effective pedicle reach with microdissection of musculocutaneous perforators during anterolateral thigh (ALT) free tissue harvest. METHODS: A review of our institution's free flap database was performed to identify ALT free tissue transfers. The distance from pedicle vessel origin to its perforator's insertion at the fascia lata (effective pedicle length [EPL]) was measured prior to and following intramuscular dissection of musculocutaneous perforators. Pertinent clinicopathologic variables were abstracted from the electronic medical record. RESULTS: A total of 314 ALT free flaps were performed between February 2017 and August 2022. Of these, 85 had documentation of EPL before and after musculocutaneous perforator dissection. ALT reconstruction was primarily performed for reconstruction of oncologic ablative defects (66, 78%). The mean EPL prior to perforator microdissection was 8.8 cm (standard deviation, SD 2.8 cm; range 3-15 cm). Following perforator dissection, mean EPL significantly increased to 14.0 cm (SD 3.0 cm; range 7-22 cm) with a mean net gain of 5.2 cm in distance (95% confidence interval 4.8-5.6 cm; p < 0.001). Nine patients (11%) required operating room take-back for anastomosis revision (3, 3.5%), recipient site hematoma evacuation (4, 4.7%), and wound dehiscence (2, 2.3%); one complete flap loss due to venous thrombosis was observed. CONCLUSION: Dissection of musculocutaneous perforators during ALT free flap harvest can increase effective pedicle reach by 5.2 cm or nearly 60%. This harvest technique can facilitate the performance of tension-free anastomoses when substantial vascular pedicle length or vascular pedicle tunneling is required. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:666-670, 2024.

Comparison of complication rates for unilateral and bilateral percutaneous nephrolithotomy (PCNL) using a modified Clavien grading system.

OBJECTIVE: To compare complication rates of unilateral vs bilateral percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. PATIENTS AND METHODS: Single-institution retrospective chart review. Identified patients who had synchronous bilateral PCNL (B-PCNL) over an 11-year period (2000-2011). B-PCNL patients were matched by age, gender, and stone burden per renal unit with patients who underwent unilateral PCNL (U-PCNL) over the same period. Complications were recorded and classified using the modified Clavien classification system, and then compared with a two-sided chi-square test of proportions. RESULTS: In all, 47 B-PCNL patients [mean (range) age 54 (14-84) years] and 78 U-PCNL patients [mean (range) age 54 (17-91 years] were compared. The mean (range) stone burden per renal unit was 2.8 (0.7-7.0) cm and 2.9 (0.7-9.0) cm, respectively. The overall complication rate was higher for B-PCNL (53.2% vs 30.8%, P = 0.013). Rates of Grade I and Grade II complications trended toward being higher in the B-PCNL group. Low-grade complications (Grade I and II combined) occurred more often in the B-PCNL group (P = 0.011); the most common low-grade complication was fever. Two procedures terminated for poor visualisation due to bleeding were successfully completed in delayed fashion with no transfusion and were classified as Grade I complications. There were equivalently low rates of Grade III complications. There were no Grade IV or V complications. CONCLUSIONS: B-PCNL carries a higher overall complication rate than U-PCNL when the modified Clavien system is used for classification. Patients undergoing U-PCNL who have more than one tract dilatation have a higher complication rate than those who have only one tract dilatation. High-grade complications are uncommon for both procedures.

Diagnosis and Management of Orbital Fat Exposure During Endoscopic Sinus Surgery.

BACKGROUND: The orbital complication rate during endoscopic sinus surgery (ESS) is <1%. Orbital fat exposure during ESS can herald orbital complications including orbital hematoma, extraocular muscle trauma, optic nerve injury, or blindness. The objective of this study was to evaluate the current consensus regarding diagnosis and management of orbital fat exposure during ESS. METHODS: A 24-point survey focused on orbital fat exposure during ESS was distributed to American Rhinologic Society members. Also, a retrospective review of 25 cases of orbital fat exposure drawn from the principal investigator's 30-year experience was performed. RESULTS: Over 10 000 surgical cases of the principal investigator were reviewed. Twenty-five patients had orbital fat exposure. Five developed minor complications while 2 were major (ie, temporary vision changes). Two hundred thirty-six surgeons responded to the survey; 93% had encountered orbital fat during ESS; 88% of surgeons identify orbital fat by either its appearance endoscopically or the "bulb press" test. Almost every responding surgeon will cautiously avoid further manipulation in the area of orbital fat exposure. Nearly half will immediately curtail the extent of surgery. Surgeons do not significantly change postoperative management. Considerations regarding observation in postanesthesia care unit, close follow-up, and strict nose blowing precautions are common. CONCLUSION: Orbital fat exposure during ESS is a rarely discussed, but clinically important. Orbital fat exposure can be a harbinger for major orbital complications that should be recognized by endoscopic appearance and confirmed with the bulb press test. Caution with "no further manipulation" of orbital fat is the guiding principle for intraoperative management, while postoperative management is generally expectant.Level 4 Evidence.

Advanced Techniques in Nonsurgical Rhinoplasty.

For a multitude of reasons, facial plastic surgeons should be adept and comfortable with nonsurgical rhinoplasty. An intimate knowledge of nasal vascular anatomy, filler choice, and proper placement can make this a safe, effective, and long-lasting treatment. Basic techniques include dorsal augmentation and camouflaging of a dorsal hump. Advanced maneuvers are also possible, including increasing tip rotation and projection, straightening the nose, lowering alar rims, and potentially the improvement of nasal function.

An update in facial gender confirming surgery.

PURPOSE OF REVIEW: To summarize current surgical and nonsurgical approaches to facial gender confirming surgery (FGCS) and highlight standards of care and areas of future research. RECENT FINDINGS: Gender nonconforming individuals may encounter considerable internal coping and external social stressors that may contribute to gender-associated dysphoria. FGCS provides patients the ability to align facial appearance with gender identity, using recently described advances in surgical and nonsurgical techniques. The majority of FGCS is performed on transwomen (individuals identifying as female), yielding the more common term of facial feminization surgery (FFS). Although no set protocols or standards are in place, certain procedures are commonly performed to alter sex-determining characteristics of the face, and further research may help define guidelines. As many training programs have minimal exposure to FGCS, promotion of transgender health awareness is paramount for diverse and inclusive surgical training. SUMMARY: Although demand for FGCS is increasing, there remains a need for improving surgical approaches, developing evidence-based care guidelines, and implementing education and awareness in training programs.

Older siblings are at increased risk for foreign bodies.

A prospective, case-control study was performed to describe the role that siblings play in foreign bodies of the head and neck and to recognize situations in which children are most at risk for foreign bodies. Any child or adolescent (0 to 17 years old) with a foreign body removed from the head or neck was included. The data collected included location of the foreign body, location of acquisition (e.g., home), and the number of and ages of siblings. Controls were matched by age, sex, and location of removal (clinic, operating room, or emergency department). Thirty-four patients were enrolled (20 male, 14 female). The average age was 5.25 years (range: 10 months to 15 years). The average age of patients with foreign bodies in the ear was 5.98 years (n = 23), esophagus 4.34 years (n = 6), and nose 2.97 years (n = 5). Nineteen (56%) of the foreign bodies were acquired at home and 17 (50%) under supervision by parents. Children with a younger sibling have a significantly increased risk of acquiring a foreign body compared with children without a younger sibling (odds ratio = 4.00, p = 0.04). We conclude that although acquisition of foreign bodies should become less common as children mature, older siblings (i.e., children who have a younger sibling) are at increased risk for foreign body acquisition. Most foreign bodies are acquired at home under supervision by parents. Increased awareness of this finding may help prevent foreign bodies in the head and neck.

Should all branch-duct intraductal papillary mucinous neoplasms be resected?

BACKGROUND: The relationship between branch-duct intraductal papillary mucinous neoplasms (IPMNs) and malignancy remains controversial and difficult to assess. METHODS: Between January 1, 1999 and January 1, 2013, we identified 84 patients with IPMN who underwent resection. RESULTS: Preoperatively, 55 patients underwent endoscopic ultrasounds and 58 underwent biopsy. Only 7 lesions were specified preoperatively as branch-duct, which inconsistently correlated with the surgical specimen. Of the 82 patients where the duct was specified, there were 33 malignant lesions. There was no correlation between branch-duct origin and invasive carcinoma. Malignant tumor size did not significantly differ by the duct of origin. Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion. CONCLUSIONS: Our study supports the resection criteria for branch-duct IPMN based on size and symptoms. However, it also questions the reliability of our preoperative testing to rule out malignant branch-duct IPMN lesions.

The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over Time.

Introduction. Several histopathologic features of periampullary tumors have been shown to be correlated with prognosis. We evaluated their association with mortality at multiple time points. Methods. A retrospective chart review identified 207 patients with periampullary adenocarcinomas who underwent pancreaticoduodenectomy between January 1, 2001 and December 31, 2009. Clinicopathologic features were assessed, and the data were analyzed using univariate and multivariate methods. Results. In univariate analysis, perineural invasion had a strong association with 1-year mortality (OR 3.03, CI 1.42-6.47), and one lymph node (LN) increase in the LN ratio (LNR) equated with a 5-fold increase in mortality. In contrast, LN status (OR 6.42, CI 3.32-12.41) and perineural invasion (OR 5.44, CI 2.81-10.52) had the strongest associations with mortality at 3 years. Using Cox proportional hazards, perineural invasion (HR 2.61, CI 1.77-3.85) and LN status (HR 2.69, CI 1.84-3.95) had robust associations with overall mortality. Recursive partitioning analysis identified LNR as the most important risk factor for mortality at 1 and 3 years. Conclusions. Overall mortality was closely related to the LNR within the first year, while longer follow-up periods demonstrated a stronger association with perineural invasion and overall LN status. Therefore, the current staging for periampullary tumors may need to be updated to include the LNR.

Metabolic syndrome and urinary stone composition: what factors matter most?

OBJECTIVE: To determine which metabolic syndrome (MetS) factors lead to differences in stone composition in a multivariate analysis. METHODS: We retrospectively reviewed medical charts of patients who had a kidney stone removed over a 5-year period (2006-2011). MetS factors (obesity [body mass index {BMI} >30], diabetes mellitus [DM], hypertension [HTN], and dyslipidemia [DLD]) were tallied in each patient. For the latter 3 factors, medical treatment for the condition was used to tag a patient with the condition. Stone composition was determined by the dominant (>50%) component. Statistical analysis was designed to determine which MetS factors were independently associated with differences in stone composition. RESULTS: Five hundred ninety kidney stones were included in the analysis. Patients with MetS had a higher prevalence of uric acid stones and lower prevalence of calcium phosphate stones. HTN and DM were independently associated with differences in composition, specifically uric acid stones (higher proportion), and calcium phosphate stones (lower proportion). Obesity was not associated with differences in composition, although a secondary analysis of morbidly obese patients showed a higher proportion of uric acid stones and a lower proportion of calcium oxalate stones. CONCLUSION: HTN and DM are the MetS factors independently associated with differences in stone composition, specifically the uric acid and calcium phosphate components. Obesity has little effect on stone composition until a very high (>40) BMI is reached. The overall effect of MetS factors on stone type is relatively small, because most stones are calcium oxalate and MetS factors have little impact on calcium oxalate frequency.

Effect of renal function on urinary mineral excretion and stone composition.

OBJECTIVE: To determine the effect of renal function on urinary mineral stone excretion and composition of kidney stones in patients undergoing urologic intervention for nephrolithiasis. METHODS: We performed a retrospective analysis of 158 patients with 193 kidney stones who underwent endourologic intervention for nephrolithiasis. The patients were grouped by the estimated glomerular filtration rate (eGFR). The kidney stone composition and results of the 24-hour urinalysis were reported for each group. Statistical analysis was performed using the chi-square test, Kruskal-Wallis test, and analysis of variance. RESULTS: The kidney stone composition profile differed significantly between the groups, with uric acid stones associated with a lower eGFR and calcium phosphate stones associated with a greater eGFR. A lower eGFR correlated with lower urine pH, lower calcium excretion, and greater oxalate excretion. Excretion of uric acid and the body mass index did not differ between groups. CONCLUSION: Different degrees of renal function correlated with certain types of kidney stones. The urine pH was lower in patients with impaired renal function. Renal function might be an underappreciated factor that affects kidney stone composition and urinary mineral excretion.