In patients with thoracic aortic graft infection, is graft explantation and replacement superior to in situ graft preservation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether graft explantation and replacement are superior to graft preservation in patients with thoracic aortic graft infections. Altogether, more than 487 papers were found using the reported search; of these, 7 comparative studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Although thoracic aortic graft infection is uncommon following cardiac surgery, it still carries a significant risk of in-hospital mortality and poor long-term survival. Current findings in the literature are limited to retrospective cohort studies with relatively small sample sizes; also, there is a lack of randomized controlled trials on this topic. There was significant heterogeneity in patient groups and variation in surgical techniques across centres. In this context, a graft-sparing approach may be a safe therapy with comparable early mortality and late survival outcomes in carefully selected patients. The selection may include the absence of graft pseudoaneurysm, anastomotic leak and fistula; the presence of indolent infection in patients with poor clinical conditions; and significant frailty and comorbidities where the risks of surgical explantation exceed the benefits. The rate of reinfection is low following both graft replacement and the graft-sparing approach. Moreover, the use of a tissue flap improves the surgical outcomes.

Totally intracorporeal robotic ileal ureter replacement: focus on surgical technique and outcomes

BACKGROUND

The aim of the present study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations.

METHODS

Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences.

RESULTS

Median operative time was 270 (range 240-300) min. No Clavien-Dindo complication >2 was collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found.

CONCLUSIONS

Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Anylasis of Nail Bed Injuries: Cause, Outcome, Treatment

BACKGROUND

Although fingertip and nail bed injuries have a high incidence, appropriate management of nail bed injuries remains controversial. This study is the completion of data derived from nail bed injuries with follow-up of a minimum of 6 months to suggest an appropriate treatment.

METHODS

In the retrospective study, we analyzed data from 549 nail bed injuries for 6 years and age, type of injury, fractures, treatment methods, and outcomes were reviewed. Results were determined and these were divided to identical to the opposite group, abnormalities based on Zook criteria. Statistical analysis was done according to injury category (type, site, nail substitute, and fracture) and overall final grade.

RESULTS

Over 50% (293 cases) had excellent results. Rates of very good, good, fair, and poor results were 22.6%, 11.3%, 6.2%, and 6.6%, respectively. Poorer results were obtained for fold injuries, crush, and avulsive injuries. The presence of a fracture was associated with poor results.

CONCLUSIONS

The cause of poor results is thought to be multifactorial. Although, overall outcomes were good, nail splitting, nail roughness, and nail adherence can cause dirtiness, catching, bending, and various cosmetic problems. Thus, careful suture and replacement of nail to nail fold are important to reach good results.

Lumbar laminotomy and replantation for the treatment of lumbar spinal epidural lipomatosis: A case report

RATIONALE

Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by excessive overgrowth of extradural fat within the lumbar spinal canal. Surgical decompression is commonly performed to treat symptomatic SELs. Fenestration or laminectomy with epidural fat debulking was a routine surgical procedure according to the literature, that may be causing postoperative lumbar instability. In the present study, we presented a brief report of lumbar SEL and introduced another surgical approach.

PATIENT CONCERNS

A 55-year-old man complained of severe low back pain and right leg radicular pain for a year, accompanied by neurogenic intermittent claudication. He received a variety of conservative treatments, including non-steroidal anti-inflammatory drugs, acupuncture, and physical therapy. However, his pain did not diminish. Finally, a posterior epidural mass in the dorsal spine extending from the L3 to L5 level, which caused dural sac compression was found on lumbar magnetic resonance imaging. This mass was homogeneously hyperintense in both T1W1 and T2W1 images, suggestive of epidural fat accumulation.

DIAGNOSES

Lumbar SEL.

INTERVENTIONS

The patient underwent lumbar laminectomy, epidural fat debulking, and spinous process-vertebral plate in situ replantations.

OUTCOMES

The patient presented with complete recovery of radiculopathy and low back pain after surgery. Postoperative magnetic resonance imaging showed that the increased adipose tissue disappeared, and the dural sac compression was relieved. A computed tomography scan revealed the lumbar lamina in situ. He was able to walk normally and remained relatively asymptomatic for 12 months after the operation at the last follow-up visit.

LESSONS

Lumbar laminotomy and replantation provide an ideal option to treat lumbar SEL because it can achieve sufficient and effective decompression, simultaneously reconstruct the anatomy of the spinal canal, and reduce the risk of iatrogenic lumbar instability.

Frozen elephant trunk infection: to defrost or to debranch?

Infections of frozen elephant trunk hybrid prosthesis (HP) are not well documented in the literature and their management is not standardized yet. We report herein the case of a 59-year-old patient who benefited from a Thoraflex™ HP aortic arch replacement for an acute type A aortic dissection. He presented a year later with a Staphylococcus aureus infection of the proximal part of this prosthesis. We performed a replacement of the proximal compound of the HP accompanied by a complete debranching of the 3 supra-aortic vessels with an inter-carotidal retro-oesophageal bypass. As we left in situ the endovascular graft within the descending aorta, a life-long antibiotic therapy was introduced. The postoperative follow-up was uneventful, and the patient discharged home 2 weeks after his surgery. As an alternative to a more radical redo surgery with major risk, a hybrid medical and surgical treatment of infected frozen elephant trunk could be considered.

Coronary Artery Reimplantation and Berlin Heart EXCOR Rescue for Left Coronary Artery Atresia With Severe Ischemic Cardiomyopathy

We describe a successful bridge to recovery by coronary reimplantation and Berlin Heart EXCOR left ventricular assist device in a child with left main coronary artery ostial atresia and severe ischemic cardiomyopathy.

Self-Inflicted Hand Amputation without Replantation in a Patient with Body Integrity Identity Disorder: A Case Report

CASE

We describe a patient who self-amputated his hand using a log splitter, because of a long-standing belief that the limb "did not belong to him." On admission, he refused replantation and was found to be nonpsychotic. He was diagnosed with body integrity identity disorder (BIID) and declared competent to make his own medical decisions. A revision amputation was performed.

CONCLUSION

BIID is a challenging diagnosis that physicians treating traumatic injuries should be aware of. Many ethicists support elective amputation as a definitive treatment, because of potential harm reduction and because BIID does not respond to conservative modalities such as pharmacotherapy.

Fast Leak-Proof, Intraumbilical, Single-Incision Laparoscopic Ovarian Cystectomy for Huge Ovarian Masses: "Hybrid Cystectomy and Reimplantation" Method

Background and Objectives: To introduce a new technique for fast leakage-proof, intraumbilical, single-incision laparoscopic ovarian cystectomy for huge ovarian masses (>10 cm) Materials and Methods: Seven consecutive, reproductive-aged women, including three adolescents, with huge ovarian masses (mature cystic teratoma, n = 4; endometrioma, n = 2; and mucinous cystadenoma, n = 1) who underwent transumbilical single-incision ovarian cystectomy with the new “hybrid cystectomy and reimplantation” method were included. The procedure was: (1) trans-umbilical single-incision laparoscopy; (2) inspection of the pelvic cavity and placing the mass in a laparoscopic endo-bag for cystic content leakage prevention; (3) in-bag resection using cold scissors and minimal cauterization of the cystectomy site; (4) in-bag tissue extraction; (5) rapid extracorporeal cystectomy with traction without electrocautery; (6) re-insertion of the retrieved ovarian cortex intracorporeally through the single port, and (7) intracorporeal suture of the retrieved tissue to the in situ ovary. Results: The mean patient age was 24.71 ± 6.56 (range 17–37) years and the mean maximal diameter of the masses was 17.71 ± 2.86 (range 13–22) cm. There was no case of unintended intracorporeal cyst rupture and no need for copious irrigation for washing and suctioning the leaked mass content. The mean total operating time was 76.42 ± 6.39 (range 65–85) min, the total volume of saline used for irrigation was 814.28 ± 331.35 (range 500–1500) mL, and the estimated blood loss was 107.14 ± 47.72 (range 50–200) mL. There were no perioperative complications. All patients except the two endometriosis patients had regular, normal menstruation. Conclusions: Our preliminary findings were encouraging in terms of the safety and efficiency of the new method. Future trials need to elucidate the benefits of this method in terms of fertility preservation.

[Pediatric ureteral ectopia: Solutions for several issues.]

OBJECTIVE

The treatment of the ectopic ureter in the pediatric patient must be individualized in each caseMETHOD: Description of clinical cases, therapeutic management and evolution of patients.

RESULTS

We present four pediatric patients with ectopic ureters who underwent surgery. We describe a case of laparoscopic nephroureterectomy, one of laparoscopic uretero-ureterostomy, one of bilateral ureteral reimplantation and another of unilateral reimplantation. The discussion about the diagnosis and different surgical treatments of each case is deepened.

CONCLUSIONS

We present four cases of pediatric patients with ectopic ureters, treated by different surgeries. We present how was the preoperative diagnosis and the importance of individualizing the surgical treatment in eachc ase. Aspects recently described in the context of ureteralectopy, such as diagnostic evaluation by MRI or the role of minimally invasive techniques in treatment, should be taken into account in its management.

Ureteral reimplantation aligned laparoscopically: Pneumovesicoscopic Politano-Leadbetter reimplantation in children

INTRODUCTION

Ureteroneocsytostomy is a well-established procedure for correction of certain ureterovesical conditions like vesicoureteral reflux and ureterevesical obstruction. Amazing developments in technology paved the way for minimally invasive surgery and conventional procedures are increasingly being performed minimal invasively during the recent decades. Although Politano-Leadbetter ureteroneocystostomy is an anatomical repair, lost its popularity against Cohen's technique as it is more challenging to perform and requires extravesical dissection which may increase the complication rates.

OBJECTIVE

In this study, we evaluated our results and feasibility of laparoscopic intravesical (pneumovesicoscopic) repair of certain ureterovesical conditions by Politano-Leadbetter principle in children.

STUDY DESIGN

Twenty one children who underwent pneumovesicoscopic uretero-neocystostomy are enrolled in the study. Surgical procedure is described and surgical duration, complications, conversion rate and success rates are evaluated.

RESULTS

Fourteen (67%) of the patients were girls and 7 were boys (33%). Median age at operation was 6 years (1.5-15 years). Main indications for surgery were vesicoureteral reflux, megaureter and bladder diverticulum. Fourteen of the patients underwent bilateral (67%) intervention while the 5 left (24%) and 2 right (9%). Four patients were converted to open surgery (16%; 4/25). Median surgical duration was 265 min (190-320 min) for bilateral and 180 min (115-260 min) for unilateral procedures. Success rates confirmed by a contrast study were 92% for VUR.

DISCUSSION

It appears that minimally invasive intravesical surgery fails to keep up with the other minimally invasive procedures secondary to restricted working field in the bladder, technically demanding procedures and well-documented high succes rates of open counterpart techniques. Although developing relatively slower, minimally invasive technology offers better vision, better cosmesis, lesser pain and lesser tissue disturbance. Although cross-trigonal reimplantation is the most popular technique, Politano-Leadbetter technique provides an anatomical alignment of ureters and is a good option for caudally located ectopic ureters. In our study, pneumovesicoscopic approach provided anatomical reimplantation, identification and sparing of vas deferens and better cosmesis. Major limitations of our study are the limited number of cases, longer operation times, higher complication rates and short follow up duration which we hope to improve with increasing experience.

CONCLUSION

Although not brilliant as its open counterpart yet, initial results of pneumovesicoscopic reimplantation with Politano-Leadbetter technique is promising and growing experience would further improve the results and lower the complication and conversion rates.

[A Simulation Surgery of Valve-sparing Aortic Root Replacement Using a Three-dimensional Printed Model]

Aortic valve-sparing surgery is a delicate procedure that requires specialized skills to control aortic valve regurgitation. Therefore, simulating the surgery before performing it on a patient is good practice for inexperienced surgeons. Herein, we present our experience of a simulation surgery using a three-dimensionally printed aortic root model of a 60-year-old man with severe aortic regurgitation and aortic root enlargement. We fabricated the model using multi-slice computed tomography data. The model revealed the two pitfalls:unbalanced commissure position and lower coaptation height of the right coronary cusp. We completed the simulation surgery from the proximal suture and valve reimplantation to coronary ostial reconstructions during approximately three hours with medical staffs. In the actual operation, the aortic valve regurgitation completely disappeared by accurately reconstructing the commissure in the Valsalva graft and adjusting the height of the right coronary cusp using central plication procedure. We believe that carrying out simulations before the actual surgery improves the surgeon's confidence and the patient's outcomes.

[Extravesical reimplantation of heavily-dilated ureters according to Bradi technique]

INTRODUCTION

Surgery of the ureterovesical anastomoses lesions in case of weakly-dilated ureters is well developed by the Cohen and Lich-Grgoire techniques. However, there are no generally accepted approaches for heavily-dilated ureters. The experience of creating ureterocystoneoanastomosis according to the Bradi technique (1975) for the first time in the literature is presented.

MATERIALS AND METHODS

The authors modification of the Bradi technique was used in 12 patients of both sexes with a dilated ureters diameter of more than 10 mm. Two cases of refluxogenic and 10 cases of obstructive megaureter were operated on 2010-2019. The follow-up period was 1-10 years. All patients underwent resection of the ureter in width.

RESULTS

No intraoperative complications were noted. One case of acute pyelonephritis with acute urinary retention was noted as postoperative complications. All patients showed a decrease in dilatation of the pyelocaliceal system and ureter according to multispiral computed tomography after 6 months of follow-up. Two patients had vesicoureteral reflux of the first degree. Glomerular filtration rates decreased in 41.7% of cases after 12 months of follow-up. No recurrence of urinary tract infection and stenosis of the anastomosis was detected for 1-10 years monitoring.

CONCLUSION

The Bradi technique along with the Hodgsons ureter reconstruction provides superior results for heavily-dilated ureters in adults.

The Skirt and Collar of The Valsalva Graft: One Dress Fits All

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation

IMPORTANCE

Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation.

OBJECTIVE

To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020.

EXPOSURES

Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation.

MAIN OUTCOMES AND MEASURES

Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes.

RESULTS

Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.

Stent-assisted balloon-induced intimal disruption and relamination in complicated chronic residual type B aortic dissection after frozen elephant trunk treatment

CASE REPORT

a 77-year-old man presented to our Emergency Department for worsening dyspnea. A chest CT scan showed a type A aortic dissection with a dilatation of the ascending and descending aorta. After evaluating the case with cardiac surgeons, it was decided to perform an aortic arch replacement through the frozen elephant trunk technique. Three months after cardiac surgery, a TC scan showed a residual 58 mm dissecting aneurysm of the descending thoracic aorta and a collapse of the true lumen so we decided to perform an endovascular treatment of the thoracoabdominal aorta according to the STABILISE technique. Due to the impossibility of cannulating the left renal artery (originating from the false lumen), a partial dilation of the dissecting stent was performed at the origin of the renal arteries, maintaining the communication between true and false lumen at the level of the aortic bifurcation.

DISCUSSION

the STABILISE technique can be applied safely and effectively even in selected cases of residual chronic aortic dissection, constituting a safe and effective alternative to open thoracoabdominal surgery.

CONCLUSIONS

the presence of a proximal artificial neck without proximal tears in the aortic arch can be a great advantage for subsequent endovascular interventions. It is therefore desirable to design a common surgical strategy within an aortic team to achieve a more favorable preoperative anatomy.

KEY WORDS

Chronic dissection, Frozen elephant trunk, STABILISE.

The 2018 New Definition of Periprosthetic Joint Infection is Valuable for Diagnosis of Persistent Infection at Reimplantation in Patients without Synovial Fluid

BACKGROUND

Diagnosis of persistent infection at reimplantation of 2-stage exchange revision is a challenging problem. The aim of our study is to evaluate the performance of the 2018 new definition and Musculoskeletal Infection Society (MSIS) criteria in determining the persistent infection at reimplantation in patients without synovial fluid.

METHODS

We retrospectively reviewed 150 patients who underwent 2-stage exchange revision from 2014 to 2018. Two models were used to define persistent infection-model 1: identical major criteria of the MSIS criteria and new definition and model 2: identical major criteria of 2 criteria and/or subsequent infection after reimplantation. The predictive accuracy of the new definition and MSIS criteria was compared by using receiver operating characteristic curves.

RESULTS

The receiver operating characteristic curves showed that the new definition had good performance in determining the persistent infection, with the area under the curve (AUC) of 0.871 in model 1 and 0.835 in model 2. The optimal threshold for aggregate scores in new definition was 4. The MSIS criteria had limited diagnostic value in both model 1 (AUC = 0.708) and model 2 (AUC = 0.664). In model 1, the sensitivity and specificity were 86.96% and 84.25% in new definition, and 47.83% and 93.70% in MSIS criteria in patients without synovial fluid. In model 2, the sensitivity and specificity were 78.57% and 85.25% in new definition, and 39.29% and 93.44% in MSIS criteria.

CONCLUSION

The 2018 new definition of PJI is valuable in the diagnosis of persistent infection, which can improve diagnostic accuracy compared with the MSIS criteria in patients without synovial fluid.

[Microsurgical replantation of traumatic amputated lip]

This is a case report of two patients with traumatic amputated lip due to respectively human bite and bicycle head-on-car collision. Both patients were successfully treated by microsurgical replantation within 24 hours and with post-operative leech treatment. Furthermore, a MEDLINE/PubMed search was performed for all scientific English articles of lip amputation and replantation using microsurgery. We want to address the importance of preserving amputated parts and the necessity of 24-hour access to plastic surgery and microsurgery in trauma if needed.

A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation

OBJECTIVE

When considering treatment for vesico ureteric reflux via inimally invasive surgery there is a dilemma to choose between laparoscopic extravesical (LEVUR) and transvesicoscopic (TVUR) ureteric reimplantation. In this systematic review and meta-analysis we have analyzed the articles on LEVUR and TVUR and compared the outcomes.

METHODS

We searched the databases to identify all papers pertaining to TVUR and LEVUR in the pediatric population. Duplicate publications, review articles, incomplete articles and robotic assistance were excluded. Systematic review was performed to identify patient data, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Meta-analysis of heterogeneity was reported with I 2 statistics. Once heterogeneity was found low, the pooled outcomes were compared with students t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 45 articles, 23 articles were included (13 articles on TVUR and 10 articles on LEVUR). The I 2 statistics for TVUR and LEVUR showed low heterogeneity with I 2 of 0% (95% C.I 0-37%) and 25% (95% C.I 0-64%) respectively. With low heterogeneity both were suitable to be considered to have been conducted under similar conditions with possibility of using fixed effect model. The percentage of Grade 5 VUR was significantly higher (p = 0.001; X 2) in TVUR (11.9%) compared to LEVUR (2.2%). The proportion of bilateral reimplantation was significantly higher (p = 0.001; X 2) in TVUR compared to LEVUR (summary table). The success rate of LEVUR was significantly higher at 96.7% compared to TVUR at 93.7% (p = 0.007 X 2). Unilateral/Bilateral TVUR took significantly longer duration of surgery (155/194 min vs 107/161 min) compared to LEVUR (p = 0.001; Fishers). The mean (s.d) time to discharge was longer at 3.2 (1.6) days for TVUR compared to 1.6 (0.4) days for LEVUR (p = 0.001; Fishers). The complication rate was comparable, 7.35% for TVUR and 5.35% for LEVUR (p = 0.167; X 2).

DISCUSSION

In this meta-analysis we found that LEVUR had shorter operating time, higher success, and shorter hospital stay compared to TVUR. A probable explanation could be higher number unilateral VURs and lower number of grade 5 VUR cases in LEVUR group. Both the techniques had comparable overall complication rate: LEVUR had more post-operative urinary retention while TVUR had more port-related problems.

Robotics in Pediatric Urology: Evolution and the Future

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Classification and clinical evaluation of "spare parts" procedures in mutilating hand injuries

Mutilating hand injuries are common, and reconstruction should be tailored to each case. The "spare parts" concept relies on harvesting tissues for reconstruction from amputated or non-salvageable parts that are being discarded. This study sought to evaluate the outcomes of "spare parts" procedures in mutilating hand injuries and to propose a classification of "spare parts" types. This study included 28 patients with mutilating hand injuries undergoing surgery using "spare parts" for tissue reconstruction either at the time of trauma or later on. A total of 31 "spare parts" procedures were performed on the 28 patients. The outcomes were assessed in terms of reconstruction success, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, and an overall patient satisfaction score that we designed. Reconstruction using "spare parts" was successful in 25 patients (89%). The mean DASH score was 8.45 ± 4.74, the mean grip strength was 24.57 ± 2.73 kg, and overall patient satisfaction was 3.32 ± 0.77 out of 5. Specific outcomes were assessed using case-specific measures. Based on these data, a hand-specific classification of "spare parts" procedures was designed to be taken into consideration when managing mutilating hand injuries. Besides direct digital replantation and tissue harvesting from different donor sites, the "spare parts" concept is an important tool for a hand surgeon. Its different types should always be taken into consideration when managing mutilating hand injuries to avoid additional donor site morbidities and to achieve a high level of overall patient satisfaction. We propose adding a "patient satisfaction with hand appearance" item to the DASH and QuickDASH score.