RESUMO
OBJECTIVES: To present our novel technique and step-by-step approach to bipolar diathermy circumcision and related procedures in adult males. METHODS: We reviewed our technique of bipolar circumcision and related procedures in 54 cases over a 22-month period at our day procedure center. Bipolar diathermy cutting and hemostasis was performed using bipolar forceps with a Valleylab machine set at 15. Sleeve circumcision was used. A dorsal slit was made, followed by frenulum release and ventral slit, and was completed with bilateral circumferential cutting. Frenuloplasties released the frenulum. Preputioplasties used multiple 2-3 mm longitudinal cuts to release the constriction, with frenulum left intact. All wounds were closed with interrupted 4/0 Vicryl Rapide™. RESULTS: A total of 54 nonemergency bipolar circumcision procedures were carried out from November 2010-August 2012 (42 circumcisions, eight frenuloplasties, and four preputioplasties). Patients were aged 18-72 years (mean, 34 years). There was minimal to no intraoperative bleeding in all cases, allowing for precise dissection. All patients were requested to attend outpatient reviews; three frenuloplasty and two circumcision patients failed to return. Of the remaining 49, mean interval to review was 49 days, with a range of 9-121 days. Two circumcision patients reported mild bleeding with nocturnal erections within a week postoperatively, but they did not require medical attention. Two others presented to family practitioners with possible wound infections which resolved with oral antibiotics. All 49 patients had well-healed wounds. CONCLUSION: The bipolar diathermy technique is a simple procedure, easily taught, and reproducible. It is associated with minimal bleeding, is safe and efficient, uses routine operating equipment and is universally applicable to circumcision/frenuloplasty/preputioplasty. In addition, it has minimal postoperative complications, and has associated excellent cosmesis.
RESUMO
Arteriovenous fistula (AVF) dysfunction is a common problem in hemodialysis patients. After surgical revision for malfunction, we used AVFs early to avoid complications associated with central venous catheters. In this study, we report experience with surgical revisions of native AVFs with suspected arterial dysfunction as the cause of inadequate arterial inflow for dialysis. Exclusion criteria were presence of a central venous catheter as a hemodialysis access, and clinical or radiologic evidence of stenosis or thrombosis of the distal venous segment of the AVF. We prospectively studied 50 patients (mean age 60.2 ± 10.5 years, 25 men and 25 women) with 59 revisions. The patients were followed until change in the modality of dialysis, transplant, or death. The types of AVFs revised were left wrist radiocephalic in 27 patients (54%), left forearm radiocephalic in 10 (20%), right wrist radiocephalic in 6 (12%), left antecubital brachiocephalic in 3 (6%), right antecubital brachiocephalic in 2 (4%), and right forearm radiocephalic in 2 (4%). The causes of inadequate arterial flow were juxta-anastomotic thrombosis in 20 patients (40%), inadequate arterial anastomotic flow in 16 (32%), inadequate anastomosis in 7 (14%), and juxta-anastomotic venous stenosis in 7 (14%). The primary surgical revision techniques were proximal neo-anastomosis using the semiarterialized vein in 43 patients (86%), thrombectomy and re-anastomosis in 5 (10%), and resection and repair in 2 (4%). Technical success, defined as successful cannulation of the revised AVF for hemodialysis and avoidance of central venous catheter, was achieved in 44 of 50 patients (88%). Technical failure occurred 6 cases, the causes being inadequate arterial flow in 3 patients, failure to cannulate the veins in 2 patients, and steal syndrome in 1 patient. After primary revisions failed, 9 re-revisions were done in 6 patients. The 1-year, 2-year, and 3-year primary and overall patency rates were 76.2%, 67.6%, 65.0%, and 85.7%, 75.7%, 65.0%, respectively. In conclusion, surgical salvage of the AVF with inadequate arterial flow is an effective approach that can be performed as an outpatient procedure and allows early cannulation of the semi-arterialized veins, thus avoiding the use of central venous catheters.