Posterior Positioning of Levator Veli Palatini with Intact Nasal Layer and Side-by-Side Bilateral Buccinator Flaps: Modified Approach for Palatal Lengthening.

OBJECTIVE: To introduce a modified surgical method using bilateral buccinator flaps with posterior positioning of levator veli palatini muscles to treat velopharyngeal insufficiency. DESIGN: Cross-sectional clinical study. PATIENTS: Non-syndromic patients with velopharyngeal insufficiency. INTERVENTION: We performed a modified surgical method using posterior positioning of levator veli palatini muscles and side-by-side bilateral buccinator flaps. MAIN OUTCOME MEASURES: Patients' characteristics, severity of hypernasality, palatal lengthening size, and operative complications were recorded and described. The severity of hypernasality was determined by a speech therapist before and after the operation. RESULTS: A total of 26 non-syndromic patients, with a median age of 8.5 years, were enrolled. All patients presented with severe hypernasality. Following the operation and during the follow-up period, 12 patients showed a complete resolution of hypernasality, while 9, 3, and 2 patients exhibited mild, moderate, and severe hypernasality, respectively. In addition, the mean palatal lengthening was measured to be 25.3 ± 3.5 mm. Overall, three patients experienced partial flap loss in one flap, which was successfully repaired with a secondary intention without the development of a fistula. In five cases, complete closure of the donor sites couldn't be achieved and thus were treated with secondary intention. Additionally, postoperative food restrictions were observed in seven cases but were resolved within one month. No other complications were noted in the remaining patients. CONCLUSION: This modified palatal lengthening technique results in a significant lengthening of the palate while maintaining favorable speech outcomes. Future randomized clinical trials are warranted to validate our findings.

Pleural epithelioid hemangioendothelioma in a 39-Year-old female: a case report.

BACKGROUND: Epithelioid hemangioendothelioma (EHE) is a rare malignancy of vascular origin which can be primarily be seen in various tissues. EHE originating from the pleura is an even more uncommon subtype which may mimic mesothelioma and pleural carcinomatosis. The prognosis of pleural EHE is poor and there is no consensus on the optimal therapeutic approach. CASE PRESENTATION: A 39-year-old middle-eastern female presented with progressive dyspnea and left shoulder discomfort. Chest computed tomography scan revealed a left side pleural effusion and pleural thickening. Pleuroscopy was done and biopsies were taken which were positive for CD31, CD34, CK, factor 8-R-antigen, and vimentin. Patient was diagnosed with pleural epithelioid hemangioendothelioma (PEHE) and chemotherapy was started and underwent extrapleural pneumonectomy 7 months later. Unfortunately, the patient passed away 10 months after diagnosis due to disease complications. CONCLUSIONS: Once PEHE is suspected in histology it can be confirmed with immunohistochemistry. Chemotherapy, surgery or a combination of both is currently used as the treatment but the standard treatment remains a question.

Predictive factors of delayed bleeding after percutaneous nephrolithotomy requiring angioembolization.

Objectives: To investigate the predictive factors of delayed post-percutaneous nephrolithotomy (PCNL) haemorrhage because of arteriovenous fistula (AVF) or pseudoaneurysm (PA) and compare the factors between AVF and PA. Patients and methods: This is a case-control study with a case-to-control ratio of 1:3. Out of 5077 patients who underwent PCNL from April 2015 to April 2018 in three different teaching hospitals, 113 had post-PCNL haemorrhages because of AVF and/or PA. Seventy-two patients met the inclusion criteria and entered the study as cases, while 216 patients without any postoperative complications were selected as controls. Results: Of all 72 studied patients with complications after PCNL, 35 (48.6%) had AVF, and the rest had PA. The regression model revealed that a history of diabetes (odds ratio [OR]: 2.799, 95% confidence interval [CI]: 1.392-5.630, p-value = 0.004) and renal anomalies (OR: 2.929, 95% CI: 1.108-7.744, p-value = 0.03) were associated with developing delayed post-PCNL haemorrhage. However, no differences were seen between AVF and PA regarding selected variables (p-value > 0.05). Conclusion: History of diabetes and renal anomalies were predictive factors for delayed post-PCNL haemorrhage, but no predictive factors were found to differentiate PA and AVF from one another.

Has the COVID-19 pandemic affected ureteral stone management in pregnant women? A retrospective single-center study.

INTRODUCTION: This study aimed to evaluate the effect of coronavirus disease (COVID-19) on the patients' referral in the pregnant population and also investigate each treatment approach's advantages and disadvantages for acute renal colic in pregnancy. METHODS: In this retrospective study, we included all pregnant women with ureteral stones referred to a referral center between January 2019 and March 2021. RESULTS: Among 53 pregnant women, 18 (33.9%) were on conservative therapy, which passed the stone without any complications. Double J stent or nephrostomy tube insertion was done for 24 patients (45.2%). Seventeen of these patients (70.8%) presented post-surgical complications, including hematuria (29.2%), pyelonephritis (20.8%), and lower urinary tract symptoms (20.8%). Transurethral lithotripsy (TUL) was done in 11 patients (20.7%). Only one of these patients developed hematuria following TUL. Thus, in our population study, double J stent or nephrostomy insertion was associated with a higher chance of postoperative complications than TUL (p-value = 0.001). Thirty-six patients were referred within 13 months before the entry of COVID-19, while 17 were referred during a similar approximate duration after the COVID-19 entry into the country. Only the initial presentation had a significant difference between these two periods (p-value = 0.034). CONCLUSIONS: When conservative treatment fails, we recommend TUL as the second-line treatment over temporary procedures, such as double J stent or nephrostomy insertion. Of note, in a group of patients with an emergent clinical setting, including active infection, deteriorating renal function, signs of preterm labor, solitary kidney, etc., double J or nephrostomy tube insertion remains the preferred management method for its fast resolution of obstruction and infection. Besides, a decrease in visits with an increase in complicated cases after COVID-19 was observed, maybe due to a delay in referring.

Three rare etiologies of urinary retention in pediatrics: A case series and review of the literature.

Etiology of urinary retention in pediatric age differs significantly from adults and the elderly. Therefore, a comprehensive diagnosis is crucial before specific treatment. Every effort must be made to minimize invasive procedures as far as possible in children.

A massive immature mediastinal teratoma treated with chemotherapy and surgical resection: a case report.

BACKGROUND: Teratoma is a type of germ cell tumor consisting of one or multiple tissues derived from germinal layers. The location and size of the tumor can cause various presentations. Here we report one of the largest ever cases of immature cystic teratoma. CASE PRESENTATION: In this report, we presented a 24-year-old patient with dyspnea, chest pain, nausea, and anorexia. A computed tomography scan revealed a giant, right-sided mass measuring about 190 × 150 × 140 mm. Chemotherapy was initiated for the patient, followed by thoracotomy. Histopathological evaluation revealed the nature of the mass to be an immature mediastinal teratoma. CONCLUSION: the incidence of immature mediastinal teratoma is uncommon, and due to its rarity, the diagnosis needs more profound evaluation studies such as radiological and pathological assessments. Immature teratomas are optimally treated by a combination of chemotherapy and complete resection.

Large Retroperitoneal Teratoma Presenting with Unilateral Hydronephrosis in an Infant: A Case Report and Review of the Literature.

Teratoma is a type of germ cell tumor layer that appears in the gonadal, sacrococcygeal, mediastinal, and retroperitoneal regions. Primary retroperitoneal teratoma is rare and asymptomatic but can present with symptoms due to a mass effect on neighboring organs. These tumors have to be considered in the differential diagnosis of a mass in the abdominal cavity of children to distinguish between Wilms' tumor, neuroblastoma, and other intra-abdominal lesions. We presented an infant boy with protrusion of the left upper quadrant of the abdomen and a palpable abdominal mass that had progressively enlarged. An abdominal computed tomography scan revealed a large retroperitoneal cystic, solid mass on the left side of the abdominal cavity, causing pressure on the left ureter. Also, hydronephrosis of the left kidney was seen with a decreased enhancement of the left kidney due to obstruction uropathy. The mass was suspicious on imaging for a retroperitoneal teratoma. The patient underwent laparotomy, and excision of the huge retroperitoneal mass was done. The final diagnosis was an immature teratoma grade 3, and the patient was discharged in good condition. Retroperitoneal teratomas are rare tumors in infants. These tumors would be an incident diagnosis or diagnosed by the mass effect of giant tumors on other organs. They must be considered in the differential diagnosis of intra-abdominal tumors in children. Hydronephrosis and obstructive uropathy can be rare consequences of the mass effects of these tumors.

Surgical removal of an unusual huge solitary fibrous tumor in the mediastinum: a case report.

BACKGROUND: Intrathoracic Solitary Fibrous Tumors (SFT) mainly arise from the pleura; however, these tumors may also originate from the mediastinum. We present a rare case of posterior SFT extending to several mediastinal sites and with an unusual large size, successfully treated with surgical resection. CASE PRESENTATION: A 66-year-old female presented with an initial manifestation of ambiguous pain in the chest and dysphagia and later developed pitting edema in both lower extremities and cachexia five months before admission. Chest imaging confirmed a mediastinal mass (17 × 15 × 8 cm) which was surgically removed. Immunohistochemistry confirmed the diagnosis of a solitary fibrous tumor with positive B-cell lymphoma 2, STAT6, and CD99, negative S100 and smooth muscle actin, and low levels of Ki67 (5-7%). The patient's follow-up course was unremarkable. CONCLUSION: Mediastinal SFTs may grow extremely huge, with the potential to invade multiple adjacent sites. Surgical removal of the tumor remains the mainstay of treatment in these cases.

Long-term outcomes of the classic Konno-Rastan procedure in paediatric and adult patients: impact of aortic annulus size on patient outcomes.

OBJECTIVES: The classic Konno-Rastan procedure may yield different outcomes regarding aortic annulus diameters ≤15 mm and larger. Focusing on the effect of the diameter of the aortic annulus, we described the long-term outcomes of our patients. METHODS: The outcomes of paediatric and adult patients who underwent surgery from 2000 to 2021 were studied retrospectively. The patient population was divided into 2 groups with aortic annulus diameters ≤15 mm and >15, and the outcomes were compared between the 2 groups. RESULTS: A total of 48 patients, with a mean age of 12.24 ± 9.42 years (2-53 years) and a median follow-up duration of 8 years (7 months to 20 years) with an IQR of 5.5, were enrolled. The mean peak instantaneous pressure gradient was 78.97 ± 25.29 mmHg, which decreased to 21.43 mmHg (P-value = 0.012). The maximum left ventricular outflow tract gradient at the last follow-up was 28.21 mmHg, with the exception of 1 case with a gradient of 68.45 mmHg. The mean diameter of the aortic annulus was 15.34 ± 3.87 mm (8-23 mm), and the mean prosthetic valve size was 20.31 mm, which was 5 mm (33%) larger than the native annulus diameter. The overall mortality rate was 6.3%, with 1 death in the hospital and 2 in the first year after the surgery. The major complication rate, including mortality, heart block and reintervention, was higher in patients with ≤15 mm annulus (P-value = 0.028.) However, there was no difference between the 2 groups in follow-up. Four (8%) late cardiac reoperations were performed, none of which were related to our surgeries. CONCLUSIONS: Kono-Rastan surgery for patients with aortic valve diameter of ≤15 mm can be performed with acceptable long-term outcomes.

Three-dimensional Computed Tomography Scan of the Pelvic Bone in Isolated Epispadias: Analysis Before Surgical Correction.

OBJECTIVE: To determine intrapelvic angles and distances in pure epispadias patients and compare them to normal values. METHODS: Using three-dimensional computed tomography, 17 intrapelvic dimensions (8 angles and 9 distances) were measured in 26 patients with pure epispadias (21 boys and 5 girls). These values were compared to normal values obtained from 6 patients (5 boys and 1 girl) who underwent either pelvic or abdominopelvic computed tomography for purposes unrelated to their bony pelvis. RESULTS: Significant differences were observed in five angles (sacroiliac joint angle, S1 tilt angle, sacral curvature, superior-inferior rotation of the pelvis, and pubococcygeal angle; P-value=.016, .044, .011, .020, and .001, respectively); these show less sacral rotation toward the axial plane, more sacral curvature, inferior rotation of the pelvis, and sacroiliac joints' rotation toward the coronal plane in epispadias compared to controls. Also, two distances (pubic diastasis and anterior segment length of the pelvis; P-value=.002 and .012, respectively) had significant differences, showing wider pubic diastasis and shorter anterior segment in epispadias. However, the differences between other intrapelvic angles and distances were not statistically significant between the two groups. CONCLUSION: In addition to the explanations hypothesized for the embryology of the exstrophy-epispadias complex, there can be other etiologies for both epispadias and bladder exstrophy to explain the differences between bony anatomies of the pelvis in these patients.

Simultaneous adrenal and retroperitoneal myelolipoma resected by laparoscopic surgery: a challenging case.

BACKGROUND: Myelolipoma is a benign neoplasm of the adrenal cortex, composed of fat and hematopoietic cells. Although myelolipoma is benign, differentiation from adrenocortical cancer may be difficult. The presence of adrenal and extra-adrenal myelolipomas simultaneously is sporadic, making it a challenging case, especially when the preoperative diagnosis is ambiguous. CASE PRESENTATION: A 65-year-old man was referred to our clinic due to a mass in the adrenal fossa. In the abdominopelvic computed tomography (CT), a well-circumscribed fat-containing 78 × 61 × 65 mm bi-lobulated mass was reported in the left adrenal fossa. The first differential diagnosis was myelolipoma. The patient was then referred to our clinic for a mass excision. He was asymptomatic and was scheduled to undergo laparoscopic-assisted adrenalectomy. After adrenalectomy and mass dissection, surprisingly, another mass was detected in the retroperitoneal area. The second mass was also dissected. The final diagnosis was myelolipoma for both masses. The patient has been symptom-free for nine months after the operation. CONCLUSION: Simultaneous adrenal and extra-adrenal myelolipoma should be considered as one of the differential diagnoses. However, because this situation is extremely rare, the probability of malignancy should be highly regarded, and we suggest an obsessive approach when approaching this condition. It is essential to manage these cases on a case-by-case basis and tailor the management concerning intraoperative biopsy, the intraoperative appearance of tumors, and the location of extra-adrenal masses.

Bronchobiliary fistulae as a complication of untreated pulmonary hydatid cyst presenting with bilioptysis: A report of two cases.

We reported two patients, a 45-year-old lady and a 48-year-old man, known cases of untreated liver and lung hydatid cysts complicated with bronchobiliary fistulae. Surgery was performed, and bronchobiliary fistulae were diagnosed intraoperatively. Lobectomy was done on the lobe, which was chronically infected. Symptoms resolved after surgery in both cases. Green-colored sputum in a patient with a history of echinococcosis should raise the physician's attention to the probability of a connection between the bronchial tree and the biliary tract. Surgery in advanced cases is a suitable therapeutic option.

The impact of laparoscopic Roux-en-Y gastric bypass on sleep quality and duration after one year of follow-up.

BACKGROUND AND AIMS: Several studies have shown the association between obesity and sleep. Roux-en-Y gastric bypass (RYGB) surgery may improve sleep disturbances in patients with obesity by influencing a variety of factors. This study aims to evaluate the impact of bariatric surgery on sleep quality. METHODS: Patients with severe obesity referred to the obesity clinic of a center from September 2019 to October 2021 were collected. The patients were divided into two groups, depending on whether they underwent RYGB surgery. Medical comorbidities and self-report questionnaires regarding sleep quality, anxiety, and depression were collected at baseline and 1-year follow-up. RESULTS: 54 patients were included, including 25 in the bariatric surgery group and 29 in the control group. However, five patients in the RYGB surgery group and four patients in the control group were lost in the follow-up. Pittsburgh Sleep Quality Index (PSQI) was decreased from a mean of 7.7 to 3.8 in the bariatric surgery group (p-value<0.001). In contrast to the control group, the number of patients with obstructive sleep apnea was significantly reduced in the bariatric surgery group. CONCLUSIONS: We showed a significant improvement in sleep quality following RYGB surgery. Obstructive sleep apnea, obesity/overweight, and depressive symptoms significantly improved in our study. There is a lack of a better understanding of the association between these factors and sleep quality following surgery. Therefore, further studies are recommended regarding this issue.

Are herbal medications, with possible beneficial effects for benign prostatic hyperplasia, better to be continued during the COVID-19 pandemic?

Different strategies have been proposed to treat cytokine storm syndrome (CSS), the final deadly complication of COVID-19. One approach is to target CSS by blocking the interleukin-6 (IL-6) pathway. A promising group of medications blocking the IL-6 pathway is α-blockers, such as prazosin. First, we hypothesized that Panax ginseng, commonly known as ginseng, can be an effective therapeutic agent in preventing CSS due to its blocking activity on alpha-1 adrenergic receptors (α1-AR). Furthermore, we suggested that herbs with 5α-reductase inhibitory effects, such as Saw palmetto, Nettle root, soya, black pepper, and green tea, can have debilitating impacts on pulmonary function since they can lead to impairment of the lung's ability to regenerate. Thus, we encourage the prospective studies to explore the potential effect of herbal medications, with possible beneficial effects for benign prostatic hyperplasia, during the COVID-19 pandemic since they are commonly consumed.

Comparison of mesh fixation and non-fixation in transabdominal preperitoneal (TAPP) inguinal hernia repair: a randomized control trial.

INTRODUCTION: Mesh fixation in inguinal hernia repair, has been a controversial subject for many years. Therefore, in this study, we evaluated and compared fixation and non-fixation of mesh in Transabdominal Preperitoneal (TAPP) Inguinal hernia repair. METHODS: In this randomized control trial, 100 patients diagnosed with unilateral inguinal hernia were included. We divided the study population into two groups of fifty. For both groups, a 15 × 13 cm Prolene(polypropylene) mesh was used for repair. In the fixation group, mesh was fixed to the abdominal wall by endoscopic tacks, while in the non-fixation group, mesh was secured at the proper place without any fixation. Postoperative outcomes were complications, recurrence, and pain intensity after 1-, 3- and 6-months. RESULTS: Postoperative pain intensity in the 1st month [Median of 2 and 0, (P < 0.001)], and 3rd month [Median of 0.5 and 0, (P < 0.001)], in the fixation group were significantly higher than the non-fixation group. However, 6 months after surgery, pain intensity was almost similar for both groups. In the 6th postoperative month, only one patient experienced recurrence who was in the fixation group. The rate of recurrence and urinary retention between the groups was not significant. CONCLUSION: It was observed that until 6 months after surgery patients who received the non-fixating method of TAPP repair experienced lower levels of pain in comparison to the fixation group while other complications did not differ between the two groups. This trail was registered at www.irct.ir with Trial Registration Number of IRCT20210224050491N1.

Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism.

PURPOSE: The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism. METHODS: A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent). RESULTS: Fifteen children (ten boys, five girls, mean age of 7.6 years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2 years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients. CONCLUSION: Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.

Braun Anastomosis: A Technique for Bile Reflux Improvement After Single Anastomosis Sleeve Ileal (SASI) Bypass; a Pilot Study.

Background. Single anastomotic surgeries can increase the risk of reflux, marginal ulceration, and gastrointestinal complications. Braun anastomosis prevents bile reflux after gastric resection and gastrojejunal anastomosis surgeries. The present pilot study evaluated Braun's efficacy in a single anastomosis sleeve ileal (SASI) bypass surgery.Methods. 28 patients with a history of SASI bypass surgery from October 2017 to September 2021 were included in the study. Patients were divided into 2 groups based on having Braun anastomosis to this surgical procedure; group A: underwent SASI bypass without Braun anastomosis; group B: underwent SASI bypass with Braun anastomosis. The surgical complications in terms of bile reflux, marginal ulcer, reflux esophagitis, and gastritis were evaluated and compared between the groups. Results. Bile reflux and reflux esophagitis were seen more in group A than in group B (37.5% vs 8.3% and 18.8% vs 8.3%, respectively). In contrast, 2 patients (16.7%) in group B had marginal ulcers compared to 1 (6.3%) in group A. Also, gastritis was seen in 1 patient in each group (6.3% in group A vs 8.3% in group B). However, the differences were not statistically different. Conclusions. Braun anastomosis is probably an effective procedure to reduce bile reflux, a concern of SASI bypass. Besides, further studies with a larger study population are needed.

The Impact of Obesity Surgery on Serum Uric Acid in People With Severe Obesity: A Retrospective Study.

Studies indicate an association between hyperuricemia (HUA) and metabolic syndrome risk factors. On the other hand, obesity is a major modifiable and independent risk factor for HUA and gout. However, evidence concerning the effects of bariatric surgery on serum uric acid levels is limited and not completely clarified. This retrospective study was carried out with 41 patients who underwent sleeve gastrectomy (n = 26) and Roux-en-Y gastric bypass (n = 15) from September 2019 to October 2021. Anthropometric, clinical, and biochemical data, including uric acid blood urea nitrogen and creatinine fasting blood sugar (FBS), serum triglyceride (TG), and serum cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), were measured preoperatively and postoperative 3, 6 and 12 months. From baseline to 6 and 12 months, bariatric surgery resulted in a significant decrease in serum uric acid of patients with severe obesity (p < 0.001). The decreases in serum FBS, TG, and cholesterol of patients were significant during 6 and 12 months of follow-up (p < 0.05). However, the HDL increase of patients was not statistically significant in 6 and 12 months (p > 0.05). Besides, although patients' serum level of LDL decreased significantly during the 6 months of follow-up (p = 0.007), it was not significant after 12 months (p = 0.092). Bariatric surgery significantly reduces serum uric acid levels. Therefore, it may be an effective supplementary therapy for lowering serum uric acid concentrations in morbidly obese patients.

Evaluation of the effectiveness of prophylactic omentopexy during laparoscopic insertion of peritoneal dialysis catheter: a case-control clinical trial.

INTRODUCTION: The laparoscopic omentopexy has been described for the prevention of peritoneal dialysis catheter obstruction due to omental wrapping of the catheter. As there are some controversies and limited data regarding the outcomes of prophylactic omentopexy, we designed a study to evaluate the efficacy of prophylactic omentopexy in preventing catheter dysfunction in patients undergoing laparoscopic catheter placement. MATERIALS AND METHODS: In this randomized clinical trial, patients with end-stage renal disease during 3 months were divided into two groups of peritoneal dialysis catheter implants with and without omentopexy and subsequently evaluated regarding postoperative features. RESULTS: A total of 43 patients were evaluated, including 22 undergoing prophylactic omentopexies. There was no significant difference among the baseline features of the patients. There was also no significant difference regarding postoperative features, including peritonitis, leakage, reoperation, need for catheter removal, and mortality. CONCLUSION: Prophylactic omentopexy did not cause any significant differences in complications. In addition, there was no benefit for decreasing postoperative outflow obstruction due to omental wrapping following peritoneal dialysis catheter insertion.