Reconstruction of the Talus and Calcaneus Using a Three-Dimensional (3D)-Printed Custom Implant Following a Shotgun Wound: A Case Report.

We present a case detailing the successful reconstruction of the hindfoot in a 15-year-old male patient who suffered a self-inflicted shotgun wound. The patient had multiple complex fractures in these bones, resulting in considerable bone loss and the destruction of the articular surface. Considering the extent of the injuries and the failure of prior intervention from an outside surgeon, traditional reconstruction methods would not have adequately addressed the severity of the damage. Consequently, the treating physician opted to address the deformity using a three-dimensional (3D)-printed custom implant to salvage the limb. The treatment involved a two-stage surgical plan. The first stage encompassed debridement with the removal of antibiotic cement, which had been placed at the time of the initial injury, followed by debridement and placement of a new temporary antibiotic spacer. A 21-day course of antibiotics was administered to combat the developing osteomyelitis. Following the successful eradication of the infection, a second surgery entailed removing the spacer and residual bone, inserting the 3D-printed implant filled with bone graft, and fusing the hindfoot. Post-surgery, the patient steadily progressed from non-weight-bearing to full weight-bearing and was fully weight-bearing at five months post-surgery. He had reported significant improvements in pain and mobility. There were no complications, and the 3D-printed implant exhibited excellent integration with the surrounding bone tissue with a two-year follow-up. This case serves as a demonstration of the utility of 3D-printed custom implants in severe foot and ankle trauma, showcasing the technology's potential to revolutionize orthopedic surgery. Despite the potential risks, this approach highlights significant benefits and opens avenues for tailored reconstructions in complex orthopedic injuries.

Ectopic Pregnancy in the Round Ligament Following Bilateral Salpingectomy: A Case Report.

Ectopic pregnancies, characterized by the implantation of a fertilized ovum outside the uterine cavity, typically occur in the fallopian tubes. However, rare cases have been reported where implantation occurs in atypical locations. Round ligament pregnancy, a rare form of ectopic pregnancy, poses significant risks and can lead to life-threatening complications. This case report describes the presentation and management of a 31-year-old gravida four, para two (G4P2012) female who presented with acute left lower quadrant and pelvic pain. The patient's medical history included a prior bilateral salpingectomy. Physical examination revealed severe left lower quadrant tenderness with guarding. A positive urine pregnancy test and elevated serum quantitative beta-human chorionic gonadotrophin level of 1,735 mIU/mL (normal range: <5 mIU/mL) confirmed pregnancy. Transvaginal ultrasound revealed an empty intrauterine cavity with no gestational sac or fetal pole. A 2 cm cystic structure was identified attached to the left ovary. Ectopic pregnancy was diagnosed, methotrexate was administered, and the patient was discharged with a scheduled outpatient follow-up. However, she returned to the emergency room within 48 hours reporting persistent pelvic pain. At this moment, it was decided that emergent surgical intervention was required. The surgical exploration confirmed the presence of a ruptured ectopic pregnancy in the round ligament, requiring excision and hemostasis. This case report highlights the importance of considering abnormal localization of ectopic pregnancy as a differential diagnosis in women presenting with pelvic pain, even after bilateral salpingectomies. It emphasizes the challenges in diagnosis and management when ectopic pregnancy occurs in atypical sites and highlights the necessity for vigilant follow-up and prompt surgical intervention when medical management fails.

Correction: Neonatal Circumcision: What Are the Factors Affecting Parental Decision?

[This corrects the article DOI: 10.7759/cureus.19415.].

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception.

BACKGROUND: Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients. OBJECTIVE: We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee. STUDY DESIGN: Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA. RESULTS: Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p < 0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score. DISCUSSION: Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings. CONCLUSION: Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

Papers presented at the fall 2020 Pediatric Urologic Oncology Work Group of the Societies of Pediatric Urology meetingBladder Duplication in a Setting of VACTER Association.

Bladder duplication is a rare anomaly classified as sagittal or coronal, depending on the axis of the septum. VACTER association involves congenital anomalies affecting the vertebrae, anus, heart, trachea, esophagus, kidney and genitourinary system. This is the first description of a case of coronal bladder duplication in a patient that also presented with anomalies on the foregut and other organs that correspond to VACTER association. Pertinent literature is systematically reviewed and compared with our case.

Neonatal Circumcision: What Are the Factors Affecting Parental Decision?

INTRODUCTION: The American Academy of Pediatrics (AAP) guidelines state that the health benefits of circumcision outweigh the risks, but these benefits are not enough to recommend universal newborn circumcision. Therefore, it is the guardians' decision to circumcise their son. In this study, we assess the factors that influence the decision-making process for newborn circumcision. METHODS: A prospective study was done from January to April 2020 for newborn circumcision. AAP guidelines were used as an educational tool and given to the parents on the day of patient circumcision assessment. On procedure day, a self-reported survey regarding the reasons for circumcision and the usefulness of the guideline as an educational resource was given to guardians. RESULTS:  A total of 265 parents completed the survey. Of the study variables, the future health of the child and the circumcision status of the father were considered extremely important factors influencing the decision-making process for 168 (63.4%) and 90 (34%) guardians, respectively. The study showed that 226 (85.3%) of the parents found the AAP guidelines helpful whereas 39 (14.7%) did not. CONCLUSION:  Overall results suggest that the health of the child and the father of the child being circumcised are the primary factors that influence the guardians' decision to circumcise their child. In addition, providing parents with an educational resource such as the AAP guidelines policy statement prior to circumcision may serve as a way to supplement the discussion between parents and providers.

Predictive factors for early discharge (≤24 hours) and re-admission following robotic-assisted laparoscopic pyeloplasty in children.

INTRODUCTION: Minimally invasive pyeloplasty (MIP) for correction of ureteropelvic junction obstruction in children has significantly improved the postoperative management of these patients. In this study, we sought to examine the factors associated with early discharge (≤24 hours) in children who underwent robotic-assisted laparoscopic pyeloplasty (RALP). METHODS: We performed a retrospective chart review of all children who underwent RALP from 2012-2018 in our center. Descriptive statistics and a non-adjusted risk analysis were performed to evaluate the factors associated with early discharge (≤24h), re-admission, and complications within the first 30 days after the procedure. RESULTS: Eighty-nine patients out of 124 total pyeloplasties (72%) stayed ≤24 hours post-surgery. Of the variables analyzed, later cases were statistically associated with length of stay (LOS); the first 55 patients had a lower probability of being hospitalized for ≤24 hours (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09-0.64, p=0.004). CONCLUSIONS: RALP for children is associated with a high rate of early recovery, short hospital stay, and low re-admission and complication rates. Although not statistically significant, patients with shorter operative room time also had a shorter LOS. An increased LOS was observed in the initial patients of our series, and this is most likely explained by the initial learning curve of the team for the procedure itself and the more conservative postoperative management.

Voiding Cystourethrogram in Children With Unilateral Multicystic Dysplastic Kidney: Is It Still necessary?

OBJECTIVE: To evaluate the value of the voiding cystourethrogram (VCUG) in children with multicystic dysplastic kidney (MCDK) who have a normal versus abnormal contralateral kidney and bladder ultrasound (US), and assess the risk of having vesicoureteral reflux (VUR) or urinary tract infection (UTI) based on the US results. METHODS: A retrospective chart review including children with unilateral MCDK with postnatal US and VCUG available at our institution between January 2008 and September 2017 was performed. Analysis was done to find association between abnormal contralateral US and contralateral VUR and UTI. RESULTS: One hundred and fifty-six children were analyzed; 118(75.6%) patients had a normal contralateral kidney US, while 38(24.4%) had abnormal US. The rate of severe contralateral VUR (grade IV and V) was 2 (1.7%) and 5 (13.2%) in children with normal and abnormal contralateral US, respectively. The risk analysis demonstrated a significant association between severe VUR on the contralateral kidney and an abnormal contralateral US (odds ratio = 7.73; 95%CI: 1.43-41.81; P = 0.018) and no significant association with UTI (odds ratio = 1.58; 95%CI: 0.50-4.94; P = 0.435). CONCLUSION: Our data suggests, the rate of severe contralateral VUR in children with unilateral MCDK and normal contralateral kidney is low. VCUG should be considered for infants with proven MCKD and alterations on the contralateral kidney on US. Following patients with MCDK and normal contralateral kidney without the use of VCUG is a reasonable approach, unless there is development of signs and symptoms of recurrent UTI or deterioration of the renal function. We found that abnormal contralateral kidney US was associated with severe VUR.

Hiperplasia prostática benigna y síntomas del tracto urinario inferior / Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms

Introducción: La hiperplasia prostática benigna constituye un problema de primer nivel de atención de salud por su alta prevalencia en los hombres. Objetivo: Identificar la presencia de síntomas del tracto urinario inferior relacionados a la hiperplasia prostática benigna y su repercusión en la calidad de vida de hombres de 50 o más años de edad, sin diagnóstico previo de hiperplasia prostática benigna, que asistieron al centro de salud de la parroquia Javier Loyola. Métodos: Estudio descriptivo transversal entre noviembre del 2018 y enero 2019, que incluyó al total pacientes (106), que asistieron al centro de salud de la parroquia Javier Loyola y que aceptaron completar la Escala internacional de síntomas prostáticos. Los datos fueron analizados por medio de la estadística descriptiva y el test de χ2. Resultados: El 35,3 por ciento de investigados pertenecieron al grupo etario de 40 a 50 años, la presencia de síntomas del tracto urinario inferior leves (38,8 por ciento), moderados (39,7 por ciento) y severos (21,5 por ciento). Prevalecieron en porcentaje de participantes los desocupados (22,4 por ciento), los albañiles (23,3 por ciento), los hipertensos (26,7 por ciento), diabéticos (17,2 por ciento) y obesos (14,7 por ciento). La severidad de los síntomas del tracto urinario inferior no se asoció significativamente al tipo de ocupación. El 61,2 por ciento de pacientes presentaban síntomas del tracto urinario inferior moderados o severos y un 56,8 por ciento percibieron que su calidad de vida se veía afectada de alguna manera por los síntomas del tracto urinario inferior. Conclusiones: Preocupa el alto porcentaje de participantes con síntomas del tracto urinario inferior moderados/severos sin un diagnóstico previo de hiperplasia prostática benigna y con percepción de que su calidad de vida se ve afectada. La severidad de los síntomas del tracto urinario inferior incrementó con la edad y no a otros factores, excepto la ocupación(AU)

Introduction: Benign prostatic hyperplasia constitutes a first-level healthcare concern, due to its high prevalence among men. Objective: To identify the presence of lower urinary tract symptoms related to benign prostatic hyperplasia and its impact on the quality of life of men aged 50 years or older, without a previous diagnosis of benign prostatic hyperplasia, who attended the health center of Javier Loyola Parish. Methods: Cross-sectional descriptive study carried out between November 2018 and January 2019, which included all the patients (106) who attended the health center of Javier Loyola Parish and agreed to complete the International Prostate Symptom Scale. The data were analyzed using descriptive statistics and the chi-square test. Results: 35.3 percent of the participants belonged to the age group from 40 to 50 years. The presence was observed of mild (38.8 percent), moderate (39.7 percent) and severe (21.5 percent) lower urinary tract symptoms. There was a prevalence of unemployed (22.4 percent), bricklayers (23.3 percent), hypertensive (26.7 percent), diabetic (17.2 percent) and obese (14.7 percent) participants. The severity of the lower urinary tract symptoms was not significantly associated with the type of occupation. 61.2 percent of patients had mild or severe lower urinary tract symptoms and 56.8 percent perceived that their quality of life was affected, in some way, by lower urinary tract symptoms. Conclusions: There is concern about the high percentage of participants with mild or severe lower urinary tract symptoms, without a previous diagnosis of benign prostatic hyperplasia, and with some perception that their quality of life is affected is. The severity of lower urinary tract symptoms increased with age but not with other factors, except occupation(AU)