Modified Y-V plasty based on MRU evaluation for iatrogenic bladder outlet obliteration: a multicentre experience in China.

PURPOSE: To compare the diagnostic ability of traditional radiographic urethrography and magnetic resonance urethrography (MRU) for iatrogenic bladder outlet obliteration (BOO), and explore the efficacy and complications of laparoscopic modified Y-V plasty for patients selected based on MRU evaluation. METHODS: 31 patients with obliteration segments ≤ 2 cm and no false passages or diverticula based on MRU evaluation from eight centers in China were included. Obliteration segments were measured preoperatively by MRU and conventional RUG/VCUG and compared with intra-operative measurements. Surgical effects were evaluated by uroflow rates, urethrography, or cystoscopy at 1, 3, 6, and 12 months post-operation and then every 12 months. Postoperative urinary continence was assessed by 24-h urine leakage (g/day). RESULTS: The results showed that MRU measured the length of obliteration more accurately than RUG/VCUG (MRU 0.91 ± 0.23 cm, RUG/VCUG 1.72 ± 1.08 cm, Actual length 0.96 ± 0.36 cm, p < 0.001), and clearly detected false passages and diverticula. Laparoscopic Y-V plasty was modified by incisions at 5 and 7 o'clock positions and double-layer suture with barbed sutures. All operations were successfully completed within a median time of 75 (62-192) minutes and without any complications. Urethral patency and urinary continence rates were 90.3% (28/31) and 87.1% (27/31), respectively. Three recurrences were cured by direct visual internal urethrotomy. Four patients had stress urinary incontinence after catheter removal 14 days post-operation, with urine leakage of 80-120 g/day, not relieved during follow-up. CONCLUSIONS: Laparoscopic modified Y-V plasty based on MRU evaluation is a promising approach for iatrogenic BOO, with a high patency rate and a low incontinence rate.

Noncongenital Vaginal Obliteration: Surgical Restoration of Vaginal Patency for GVHD.

STUDY OBJECTIVE: To provide a brief overview of noncongenital causes of vaginal obliteration and stenosis, discuss a unique case of vaginal agglutination in a patient who developed genital graft-versus-host disease (GVHD) after receiving a bone marrow transplant (BMT), and present the steps of a laparoscopic total hysterectomy and lysis of vaginal adhesions that successfully restored vaginal patency without the need for grafting. DESIGN: This video gives an overview of noncongenital causes of vaginal obliteration with a focus on genital GVHD. SETTING: GVHD is a known possible complication of BMT. This condition can lead to vaginal obliteration, affecting sexual performance and quality of life. INTERVENTIONS: We discuss the clinical course of a 54-year-old female with history of acute monocytic leukemia treated with chemotherapy and a BMT. She subsequently developed genital GVHD with complete vaginal obliteration, precluding penetrative intercourse and causing pain, discomfort, and decreased quality of life. We present a combined laparoscopic and vaginal surgical procedure that allowed for the creation of a neovagina with a normal length and caliber. While grafting is sometimes necessary due to inflammation and scarring, we were able to avoid a graft by using a combined laparoscopic and vaginal approach, followed by restoration of continuity between the unaffected upper and lower vaginal tissues. CONCLUSION: GVHD can be quite debilitating for patients. A combined surgical approach is a feasible option for patients with complex pathology not amenable to simple transvaginal adhesiolysis. Surgical restoration of the vagina does not necessarily require the use of a graft if the anatomy is reestablished successfully. VIDEO ABSTRACT.

Microsurgical versus endovascular treatment of ethmoidal dural arteriovenous fistulas: systematic review and meta-analysis with a single-center case series.

OBJECTIVE: Ethmoidal dural arteriovenous fistulas (DAVFs) are often associated with cortical venous drainage (CVD) and a higher incidence of hemorrhage compared with DAVFs in other locations. They may be treated with open surgical disconnection or with endovascular treatment (EVT). In this systematic review and meta-analysis, the authors compare the outcomes of ethmoidal DAVFs treated with open microsurgery versus EVT and report four additional cases of ethmoidal DAVFs treated with open microsurgery in their institution. METHODS: A literature search of the PubMed and Scopus databases was conducted between December 2021 and May 2022 to identify relevant articles published between 1990 and 2021 using the PRISMA guidelines. References were reviewed and screened by two authors independently, and disagreements were resolved through consensus. Exclusion criteria included non-English-language studies, those with an incorrect study design, those reporting DAVFs in a nonethmoidal location, and studies whose outcomes were not stratified based on DAVF location. Inclusion criteria were any studies reporting on ethmoidal DAVFs treated by either microsurgery or EVT. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. The authors performed a pooled proportional meta-analysis to compare patient outcomes. RESULTS: Twenty studies were included for analysis. Of 224 patients, 142 were treated with surgery, while 103 were treated with EVT. Seventy percent (148/210) of the patients were symptomatic at presentation, with hemorrhage being the most common presentation (48%). CVD was present in 98% of patients and venous ectasia in 61%. The rates of complete DAVF obliteration with surgery and EVT were 89% and 70%, respectively (95% CI -30% to -10%, p < 0.03). Twenty percent (21/103) of endovascularly treated fistulas required subsequent surgery. Procedure-related complications occurred in 10% of the surgical cases, compared with 13% of the EVT cases. The authors' case series included 4 patients with ethmoidal DAVFs treated surgically with complete obliteration, without any postoperative complications. CONCLUSIONS: The complete obliteration rates of ethmoidal DAVF appear to be higher and more definitive with microsurgical intervention than with EVT. While complication rates between the two procedures seem similar, patients treated with EVT may require further interventions for definitive treatment. The limitations of this study include its retrospective nature, the quality of studies included, and the continued evolving technologies of EVT. Future studies should focus on the association between venous drainage pattern and the proclivity toward venous ectasia or rate of hemorrhage at presentation.

Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks.

BACKGROUND: Dense adhesion due to severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterates the cul-de-sac and distorts normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries, as well as voiding dysfunction. It is important to develop the retroperitoneal avascular space based on precise anatomical landmarks to minimize the risk of ureteral, rectal, and hypogastric nerve injuries. We herein report the anatomical highlights and standardized and reproducible surgical steps of total laparoscopic hysterectomy for posterior cul-de-sac obliteration. OPERATIVE TECHNIQUE: We approach the patient with posterior cul-de-sac obliteration using the following five steps. Step 1: Preparation (Mobilization of the sigmoid colon and bladder separation from the uterus). Step 2: Development of the lateral pararectal space and identification of the ureter. Step 3: Isolation of the ureter. Step 4: Development of the medial pararectal space and separation of the hypogastric nerve plane. Step 5: Reopening of the pouch of Douglas. CONCLUSION: Surgeons should recognize the importance of developing the retroperitoneal avascular space based on precise anatomical landmarks, and each surgical step must be reproducible.

Frequency of cul-de-sac obliteration in surgery for pelvic organ prolapse: a retrospective analysis.

INTRODUCTION AND HYPOTHESIS: We aimed to clarify the frequency of cul-de-sac obliteration in patients undergoing POP surgery. METHODS: We retrospectively reviewed patients who underwent laparoscopic POP surgery at our hospital between April 2017 and September 2021. RESULTS: In total, 191 cases were included in the analysis. Ten patients (5.2%) had cul-de-sac obliteration. No difference in age (73 years vs. 72 years, P = 0.99), parity (2 vs. 2, P = 0.64), or body mass index (BMI) (25.7 kg/m2 vs. 24.7 kg/m2, P = 0.34) was observed between the cul-de-sac obliteration and normal groups. No significant differences were observed in the rate of previous abdominal surgery (50.0% vs. 32.6%, P = 0.46), rate of POP - quantification system (POP-Q) ≥ 2 posterior prolapse (40.0% vs. 46.4%, P = 0.98), and effect of defecation symptoms on the prolapse quality of life (p-QOL) score (vaginal bulge emptying bowels: 2.5 vs. 3.5, P = 0.15; empty bowel feeling: 3 vs. 3, P = 0.72, constipation: 3.5 vs. 3, P = 0.58; straining to open bowels: 3.5 vs. 3, P = 0.82; empty bowels with fingers: 1 vs. 1, P = 0.55) between the cul-de-sac obliteration and normal groups. Multivariate analysis of risk factors for the cul-de-sac obliteration was performed for age, number of births, previous abdominal surgery, and presence of rectocele; however no significant risk factors were extracted. CONCLUSION: Predicting cul-de-sac obliteration preoperatively in patients undergoing POP surgery based on age, number of previous surgeries, previous abdominal surgeries, rectocele, and defecation symptoms is difficult.

Long-term clinical and radiological results for fat graft obliteration in subtotal petrosectomy and cochlear implant surgery: a retrospective clinical study.

PURPOSE: The study aimed to evaluate the long-term clinical, radiological, and functional results for subtotal petrosectomy and cochlear implant surgery with closure of the external auditory canal and fat obliteration. METHODS: We retrospectively included all consecutive cases of simultaneous subtotal petrosectomy and cochlear implant surgery performed at a tertiary referral center between 2009 and 2016 using the same surgical technique. All patients underwent postoperative high-resolution computed tomography (HRCT) and annual audiological assessments. A 5-year minimum clinical, radiological, and audiological follow-up was performed. The early and late postoperative results were compared. The main outcome measures were complications, postauricular retraction, fat graft reabsorption, and audiological outcomes. RESULTS: Twenty-nine procedures performed in 23 patients (six bilateral) met the inclusion criteria. The mean age of the patients was 67 ± 13.4 years and mean follow-up duration was 7.5 ± 2 years. At follow-up, postauricular retraction was detected in 24 cases (82.8%), including five cases (17.1%) with subcutaneous protrusion of implant and array. Fat graft volume was significantly reduced at late-HRCT in terms of maximum diameter (2.24 ± 1.0 cm vs 3.69 ± 0.7 cm; p < 0.0005) and surface area (1.88 ± 1.2 vs 4.24 ± 1.6 cm2, p < 0.0005). Six patients had extracochlear electrodes at late-HRCT (3/6 had an increased number of extracochlear electrodes), with a lowering of this group's performance of - 15% (p < 0.005) in the follow-up speech comprehension test. CONCLUSIONS: Subtotal petrosectomy with cochlear implantation is an effective long-term technique in selected cases. Fat grafts showed significant reabsorption at long-term follow-up with reaeration of the middle ear spaces. Prolonged clinical and radiological follow-up is recommended for monitoring implant performances and late complications.

External auditory canal reconstruction using a novel mastoidoplasty technique during canal wall down mastoidectomy: how I do it.

BACKGROUND: While mastoid obliteration techniques have received much attention in decreasing the disadvantages associated with the resultant mastoid cavity from canal wall down procedures, techniques for an anatomically normal looking ear canal reconstruction to increase the feasibility of hearing aid fitting are less commonly discussed as an alternative. METHODS: Our mastoidoplasty technique basically utilises an inferiorly based periosteal flap with or without temporalis muscles and fascia to obliterate the epitympanum and reconstruct the external auditory canal (EAC). Stay sutures are used to keep them in place. For larger cavities, demineralized bone matrix (DBM) is used to obliterate the mastoid cavity and support the neo-EAC. CONCLUSIONS: The concept of our mastoidoplasty potentially provides a very useful alternative in recreating a near normal ear canal anatomy avoiding cavity problems as well as facilitating hearing aid fitting with canal type hearing aids after canal wall down mastoidectomy.

Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Combined ascending aortobiiliac bypass and endovascular obliteration in the Bentall procedure for dual aortic aneurysms.

Patients with Marfan syndrome who present with a dual aortic aneurysm are not uncommon in clinical practice; however, the management of these patients is a significant challenge. We present a unique case of aortic root aneurysm and challenging infrarenal abdominal aortic aneurysm (AAA) with a short and angulated neck. We performed simultaneous repair using the Bentall procedure and ascending aortobiiliac bypass. Endovascular obliteration of the AAA neck and bilateral common iliac arteries was also performed. The perioperative process was uneventful. Normal functioning of the mechanical valve and complete thrombosis of the AAA sac were confirmed on follow-up computed tomography and echocardiography. This report suggests that combined ascending aortobiiliac bypass and endovascular obliteration with the Bentall procedure for dual aortic aneurysm is a useful surgical strategy for patients with Marfan syndrome. Life-long follow-up and medication ought to be mandatory to prevent incomplete exclusion and bypass occlusion.

Total laparoscopic hysterectomy when there is posterior cul-de-sac obliteration: a step-by-step nerve-sparing technique.

Dense adhesions because of severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterate the cul-de-sac and distort normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries and voiding dysfunction. Surgeons should recognize the importance of not only avoiding ureteral and rectal injuries but also focusing on the preservation of the hypogastric nerves. Herein, we reported the anatomic highlights and surgical steps of laparoscopic hysterectomy for posterior cul-de-sac obliteration with the nerve-sparing technique.

Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration.

INTRODUCTION: Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients. METHODS: We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments. RESULTS: During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17-15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93-0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57-24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker. CONCLUSION: The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.

Cochlear Obliteration after Translabyrinthine Resection for Large Cerebellopontine Angle Tumor.

INTRODUCTION: The aim of this study was to better understand the onset time and factors associated with cochlear obliteration following translabyrinthine approach (TLA) surgery for large cerebellopontine angle tumors. METHODS: This retrospective cohort study included 117 patients with large cerebellopontine angle tumor (tumor diameter >2 cm) treated by TLA surgery from June 2011 to March 2019 in a single tertiary referral center. The Kaplan-Meier method with log-rank test was used to estimate cochlear patency survival and the association between survival and covariates, and the Cox proportional hazards regression analysis was used to identify possible factors associated with cochlear obliteration. RESULTS: Of the 117 patients included in our analysis, the median follow-up was 24.8 months. There were 30 (25.6%) patients in the cochlear obliteration group, and 87 (74.4%) in the patent cochlear group. Various degrees of cochlear obliteration was found in 25.6% patients in final MRI scan, comprised of 50% grade I, 30% grade II, and 20% grade III. Cochlear patency survival curves showed 94.0% at 3 months, 73.0% at 18 months, which plateaued after 20 months with a survival rate of 71.6%. In the multivariate Cox proportional hazards model, patients presented with postoperative hyperintense T1W cochlear signal had poorer cochlear patency survival compared to isointense T1W (HR = 4.15). Similarly, postoperative deteriorated facial function (HR = 4.52) and full IAC involvement of tumor (HR = 2.33) demonstrated a higher risks of cochlear obliteration after TLA surgery. CONCLUSION: The 2-year estimated cochlear patency rate was 71.6% in patients that received TLA. Cochlear obliteration can develop as early as 3 months post-surgery, with no new obliteration 20 months after the surgery and half of these patients got severe obliteration. Three factors associated with cochlear obliteration were identified including full IAC involvement of tumor, postoperative facial function deterioration, and postoperative hyperintense T1W cochlear signal.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding.

OBJECTIVES: Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function. METHODS: From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups. RESULTS: Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups. CONCLUSION: EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

Four-dimensional flow magnetic resonance imaging for assessment of hemodynamic changes in the portal venous system before and after balloon-occluded retrograde transvenous obliteration: a pilot feasibility study.

BACKGROUND: The effectiveness of four-dimensional (4D) flow magnetic resonance imaging (MRI) for assessing hemodynamic changes before and after balloon-occluded retrograde transvenous obliteration (BRTO) remains unclear. PURPOSE: To evaluate the feasibility of 4D flow MRI for assessing hemodynamic changes in the portal venous system before and after BRTO. MATERIAL AND METHODS: We included 10 patients (7 men, 3 women; mean age = 67 years) with liver cirrhosis who had a high risk of gastric variceal bleeding or hepatic encephalopathy. Non-contrast 4D flow MRI of the upper abdomen was performed before and after BRTO. In addition, we compared the blood flow rates in the portal vein (PV), superior mesenteric vein (SMV), splenic vein (SV), left renal vein, and inferior vena cava before and after BRTO. Moreover, the flow directions of the SMV and SV before and after BRTO were assessed using both portography and 4D flow MRI. RESULTS: There was a significant post-BRTO increase in the blood flow rate in the PV and SV (P < 0.05). There was no significant post-BRTO change in the blood flow rates in the SMV, inferior vena cava, and left renal vein. In four patients, portography confirmed that hepatofugal flow in the SV and SMV changed to hepatopetal flow after BRTO. Moreover, 4D flow MRI correctly assessed the flow directions in the SMV and SV in 70%-100% of the patients. CONCLUSION: 4D flow MRI can be used to detect hemodynamic changes in the portal venous system before and after BRTO.

Mastoid obliteration versus canal wall down or canal wall up mastoidectomy for cholesteatoma: Systematic review and meta-analysis.

BACKGROUND: There is ongoing debate over the optimal surgical approach for cholesteatoma treatment1-5. The aim of this review was to determine whether canal-wall down with mastoid obliteration is associated with favourable outcomes compared to either canal-wall down without obliteration or canal-wall up. The primary outcome was cholesteatoma reoccurrence with secondary outcomes including otorrhoea, reoperation and patient-reported outcome measures. METHODS: Medline, Embase, Cochrane databases and clinicaltrials.gov were searched for studies reporting outcomes of patients undergoing primary CWD-MO for cholesteatoma and directly compared with CWD and CWU mastoidectomies. Data were collated and meta-analysis performed. RESULTS: 2379 patients were included from 12 studies that met the inclusion criteria. CWD-MO was found to be associated with significantly less risk of recurrence when compared to CWU (OR = 0.330 (95 % CI 0.191-0.570, p < 0.001). When compared to CWD, CWD-MO was associate with significantly lower incidence of persistent otorrhoea (OR 0.405 (95 % CI 0.232-0.706, p < 0.001) while the rates of recurrence were comparable (OR: 1.231 [95 % CI: 0.550-2.757] p = 0.613). Otorrhoea rates between CWD-MO and CWU were equivalent as was reoperation. Quality of life and hearing outcomes were variably reported. CONCLUSIONS: This systematic review demonstrates that CWD-MO technique achieves lower recurrence rates comparable to CWD approaches and superior to CWU, while offering improved long-term control of otorrhoea. The final procedural choice should be decided based on surgeon experience, skill set and individual patient factors. To address the risk of selection bias, a randomised controlled trial is needed to answer this important research question.

Cholesteatoma surgery in the pediatric population: remaining challenges in the era of mastoid obliteration.

PURPOSE: To present the first pediatric study on the safety and efficacy of mastoid obliteration using S53P4 bioactive glass (BAG) for cholesteatoma surgery. METHODS: A single-center retrospective cohort study was conducted. Inclusion criteria were pediatric cases (≤ 18 years) and at least at least one year of follow-up including non-echo planar diffusion-weighted MRI to assess cholesteatoma recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were evaluated. RESULTS: A total of 61 cases (56 patients) were included. Most cases had an otologic history before the development of the cholesteatoma. CWU procedure was performed in 18 cases (30%) and CWD procedure in 43 cases (70%). The cholesteatoma recidivism rate was 33% after a mean follow-up period of 58 months. Kaplan-Meier curve estimated a 5-year recidivism rate of 40%. Few complications were seen that were all minor and resolved spontaneously or after local or systemic treatment. Control of the infection (merchant grade 0-1) was achieved in 98% of the cases. Closure of the air-bone gap within 20 dB was achieved in 22% of the cases with complete audiometric evaluation. CONCLUSION: In this MRI-controlled study, we show the safety and efficacy of S53P4 BAG for mastoid obliteration in a pediatric cholesteatoma cohort. Postoperative complications were both rare and minor, and a dry ear was achieved in almost all patients. Nevertheless, persistent hearing loss and the apparent high recidivism rate reflect the challenging nature of pediatric cholesteatoma.

Mastoid obliteration with hydroxyapatite vs. bone pâté in mastoidectomy surgery performed on patients with cholesteatoma and chronic suppurative otitis media: a retrospective analysis.

PURPOSE: To compare the efficacy and safety of hydroxyapatite vs. bone pâté as obliteration material in mastoidectomy surgery for patients with chronic suppurative otitis media and cholesteatoma. METHODS: This is a retrospective, multi-center, cohort study. All patients were followed up with micro-otoscopy, audiometry, and, if indicated, MRI with diffusion-weighted imaging. The following outcome parameters were analyzed: procedure safety (wound infections and complications), cholesteatoma recidivism rates (residual/recurrent), control of infection (Merchant's scale), and hearing results (pure-tone averages at 500/1000/2000/4000 Hz). RESULTS: Eighty-three cases were included: 45 obliterated with hydroxyapatite and 38 with bone pâté, with a mean follow-up time of, respectively, 25 and 24 months. Wound infections were only detected in the bone pâté group (4.8%) and successfully treated with oral or intravenous antibiotics and surgical drainage (p = 0.026). No other major surgical complications were observed in both groups. Cholesteatoma recidivism was observed in 15% using hydroxyapatite and 12% using bone pâté (p = 0.471). Complete control of infection (Merchant 0) was achieved in 76.2% using bone pâté and 86.8% using hydroxyapatite at 12 months postoperatively (p = 0.223). All patients showed good postoperative healing without complete failure to manage infection (Merchant 3). Pre- and postoperative audiometry showed significant improvement in hearing results in both groups. No significant difference between the obliteration materials was observed. CONCLUSIONS: Evaluation of mastoid obliteration reveals that hydroxyapatite and bone pâté are safe and effective obliteration materials, with high success rates in achieving a dry ear, low recidivism rates, and good hearing outcome, respecting the short-term limitation. In addition, our study shows that hydroxyapatite results in fewer postoperative wound infections compared to bone pâté.

Use of bonalive in obliterative mastoidectomy: anatomical results and clinical outcome.

PURPOSE: To investigate safety and efficacy of mastoid obliteration in canal-wall-down tympanoplasty performed for cholesteatoma using bioactive glass (BAG). The authors routinely adopt CWD tympanoplasty in case of massive cholesteatoma or revision surgery, performing obliteration with BAG to reduce the mastoid cavity and related disadvantages. We assessed anatomical results, infection control and cholesteatoma recurrence in obliterative mastoidectomy using BAG. METHODS: The authors evaluated 66 patients treated with obliterative mastoidectomy using BAG during the period 2010-2021. 48.5% of the cases had first diagnosis of cholesteatoma, 48.5% had cholesteatoma recidivisms, and two patients underwent obliteration to improve clinical outcome. BAG granules were always moistened with venous blood to enhance their adhesion and reduce the risk of dispersion. Anatomical results were evaluated in otomicroscopy and infection control was assessed during follow-up visits. Periodical otomicroscopy was performed to check recurrent cholesteatoma. MRI-DWI was indicated only in case of clinical suspect of cholesteatoma. RESULTS: Authors followed 66 patients during a mean of 23 months. No post-operative wound infections occured. The mean re-epithelialization time was 45 days. At the last visit, control of infection was achieved in 97% of patients and a clinical stable anatomical cavity in all patients. No clinical suspect for recurrent cholesteatoma was found. CONCLUSIONS: The use of bioactive glass is safe and effective as obliteration material in cholesteatoma surgery. Authors pay a particular attention to obliterate only patients without suspect of epithelial residual, to correctly calibrate the ear canal and to completely cover the granules with graft.

Endovascular and surgical obliteration rates of spinal dural arteriovenous fistulae: a single UK Centre experience.

OBJECTIVE: Endovascular treatment (EVT) of spinal dural arteriovenous fistulae (SDAVF) has become increasingly popular given its less invasive nature. This study aims to assess radiological obliteration rates after surgery and EVT for SDAVF in a major tertiary referral centre serving a population of 2.2 million. METHOD: A retrospective review of all patients diagnosed with SDAVF between February 2010 and February 2018 was undertaken, identifying baseline demographics, treatment modality and the final radiological outcome (i.e., persistence of the SDAVF). Patients were identified from the departmental neurovascular database, clinical notes and imaging reports. RESULTS: Twenty patients were identified with an angiographically confirmed SDAVF. Two (10%) were managed conservatively. Nine patients (45%) underwent EVT. Obliteration was achieved in one patient (11%) after a single procedure, while one patient required two sessions. Further surgery was required in five patients (56%) to achieve complete obliteration. Nine patients (45%) underwent surgical disconnection as first treatment. Obliteration was radiologically confirmed in eight patients (89%). No radiological (MRI or angiographic) follow-up data was available for two patients (one from each group) and these were excluded from analysis. In this study, the obliteration rate of SDAVF after surgery was superior compared to EVT (p <0.01). CONCLUSION: Complete obliteration and recurrence rates after single treatment with EVT were inferior compared to surgical intervention. EVT may be better suited for specific presentations of SDAVF either in isolation or as an adjunct in multi-modality treatment. A national registry of outcomes may aid ongoing refinement of patient selection for EVT.

Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study.

BACKGROUND: To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. METHODS: This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. RESULTS: Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0 years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). CONCLUSIONS: Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.