Is a pedicular flap coupled to the double turnover flaps urethroplasty suitable for urethral-perineal reconstruction? Considerations about a relapsing urethral-cutaneous fistula condition.

Background: This study highlights the effectiveness, in one surgical stage, of two combined local techniques for perineal fistula repair in a patient with spinal cord injury: the " Turn over flaps urethroplasty" and the "Pedicular fasciocutaneous flap" from the inferior gluteal fold. Unlike the traditional Perforator flap, we harvested a Pedicular flap; by definition, this is a flap with a narrow diffuse microvascular supply aimed in our case at shielding the neourethra and substituting the remaining scarred perineum. Method: The urethroplasty technique adopted, the 'Double turn over flaps urethroplasty', has been based on sculpting two opposing local cutaneous flaps circumscribing the fistulous cutaneous openings. Eventually, the neourethra continuity has been re-established by turning over both flaps and making them meet medially. The dimension and thickness of the "Pedicular fasciocutaneous flap", have been considered to prevent any damage to the urethroplasty and at the same time to replace all the debrided scarred perineal tissue. Results: The follow-up confirmed a well-consolidated supple perineal area and a competent neourethra. Conclusions: The "Pedicular flap" is by definition a random vascular flap nourished through a narrow pedicle, not based on a single perforator but only on a diffuse, spread micro-perforators. When associated with the double "Turn over flaps urethroplasty", it represents a possible alternative to achieve satisfactory results for those physical and psychological challenges encountered in the treatment of recurrent urethral fistula of the perineum in a patient with spinal cord injury.

Extraosseus Ewing sarcoma: An uncommon periclavicular location.

A rapidly enlarging right sternoclavicular mass in a young male was labeled as a nonspecific mass. MRI played a crucial role in characterizing the lesion, helping to define the possible mesenchymal origin and the relative involvement of the surrounding structures. We also discuss the differential diagnosis of an extraosseus Ewing sarcoma (ES), with its imaging findings.

The neurogenic bladder: anatomy and neurophysiology.

Micturition disorders secondary to alterations of complex neural controls do not represent a separate, typified condition but frequently they are symptoms of more complex diseases. Unfortunately, they are often misunderstood leading to severe damages to the patient. In diagnostic imaging of neural alterations of micturition, a major role is played by voiding cystourethrography for its contribution to both the morphologic and functional aspects. The dynamics of micturition is documented by voiding cystourethrography and with the integration between radiologic morphofunctional imaging and urodynamic pressure values the type and level of the neural lesion can be better defined. Therefore, subsequent neuroradiologic study can be specifically planned. Modern diagnostic imaging allows ready detection of the frequent complications of neurogenic bladder as diverticula, lithiasis, inflammation, that, especially in some patients, if misunderstood, can be particularly severe.

Diagnostic imaging of neurogenic bladder.

Correct radiologic diagnosis of neurogenic bladder is mainly based on morphofunctional information derived from voiding cystourethrography. This examination allows the evaluation of the bladder morphology, the degree of filling, and the validity of muscular contraction. Indications on the bladder neck, striated sphincter function and urethral morphology are also provided. Presence of ureterovesical reflux is detected with its possible precise classification. Abnormal amount of residual urine is identified and often early diagnosis of most common complications of neurogenic bladder as vesical lithiasis, diverticula and infections, can be established.