Hybrid Natural Orifice Translumenal Endoscopic Surgery Transvaginal Nephrectomy in a Low-Resource Setting.

INTRODUCTION: Hybrid natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) reduces the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure NOTES, especially in the absence of angulated instruments. PATIENTS AND METHODS: The patients were 66-, 69-, and 32-year-old women with complaints of recurrent flank pain and urinary tract infection due to an obstructed nonfunctioning kidney. Materials used were standard laparoscopic instruments and a 30° 10-mm high-definition laparoscope. Under general anesthesia, each patient was placed in a lithotomy position with the affected side up at 45°. A Veress needle was initially inserted through the umbilicus and was later replaced with a 10-mm laparoscopic port, with an additional 5-mm port also inserted at the affected lower quadrant site. The patient was then positioned in a steep Trendelenburg position, and a 10-mm port was inserted through the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the laparoscope. Nephrectomy proceeded despite noted severe adhesions, and the kidney was placed in the specimen retrieval bag. The vaginal port site was enlarged to 3 cm for extraction of the specimen. A Penrose drain was placed at the lower quadrant 5-mm trocar site. The vaginal wound was repaired using running 2-0 absorbable sutures. RESULTS: Three cases of transvaginal hybrid NOTES nephrectomy were successfully completed with a median operative time of 310 minutes and mean estimated blood loss of 300 mL. Median renal dimensions were as follows: craniocaudal, 10.2 (range, 10.6-9) cm; laterolateral, 6.5 (range, 7-5.3) cm; and anteroposterior, 4.8 (range, 6.5-3.9) cm. The patients resumed regular diet as early as Day 1 postoperatively. The drain was removed prior to discharge. The mean date of discharge was Day 3 postoperatively. There were no noted surgical complications according to the Clavien-Dindo grading system. CONCLUSIONS: Hybrid NOTES transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced postoperative pain, and early recovery.

Retrospective study on perioperative complications of Fournier's gangrene: A four-year review

OBJECTIVE: The study aimed to describe the pen-operative complications of Fournier's gangrene in series of patients. METHODOLOGY: A descriptive study was done using cross-sectional study design among patients diagnosed with Fournier's gangrene from January 1, 2010 to December 31, 2013. All patients regardless of age with extensive infection of the scrotum, genitalia, or perineum who underwent debridement and wide surgical excision of scrotal and/or perineal necrosis along with other involved areas and diagnosed with Fournier's gangrene postoperatively within the study period at JRRMMC was included in the study. RESULTS: The study included 25 patients. Of these, 48% (12/25) of subjects with Fournier's gangrene had perioperative complication. Results also showed that number of hospital stay ranged from less than 24 hours to 42 days (mean of 10.5 days). Distribution of subjects by etiologic cause of Fournier's gangrene showed that majority of the etiologic cause of Fournier's gangrene were colorectal with 68% (17/25). Genital cause only comprised 32% (8/25) of the etiologic cause of Fournier's gangrene. The most frequent predisposing factor identified was diabetes mellitus. CONCLUSION: Fournier's gangrene remains a surgical and urological emergency. Many patients may present with only minor skin lesions in the early stages of the disease. Rapid and accurate diagnosis remains a key component in achieving a successful outcome.