[Microsurgical penis replantation following self mutilation]

Although amputation of the penis is a rare problem, a complete reconstruction of all penile structures should be attempted in one stage. This way the best chance for full rehabilitation of the patient can be achieved. A microsurgical reimplantation with microsurgical sutures of arteries, veins, nerves and urethra after total amputation of the penis is reported. Eight months after surgery normal appearance and function, including a good urine flow and absence of urethral stricture, capability of erection and nearly normal sensitivity, was found.

Dynamic radionuclide imaging as a means of evaluating vascular perfusion of the upper extremity: a preliminary report

Vascular competence in the upper extremities of 44 patients was evaluated by three-phase bone scans consisting of rapid sequence dynamic radionuclide imaging (DRI), an immediate postinjection "blood pool" image, and a 3- to 4-hour delayed image. Findings were correlated with definitive anatomy determined by arteriography, operative findings, or both, in 50 extremities. DRI provided the correct diagnosis in all but four extremities (92%). Limited resolution precluded precise anatomic definition of aneurysms in three limbs and of digital artery occlusion, with adequate collateral circulation in the fourth limb. The greatest value of DRI was its provision of quantitative information about relative blood flow and preferential perfusion in every instance. We believe DRI to be a useful adjunct to preoperative and postoperative assessment of arterial perfusion.

Rehabilitation of newly reconstructed thumb

This paper documents the rehabilitation of newly reconstructed thumb using five different techniques of creating a new thumb. We have attempted to assess the functional usefulness that each method offers to the recipient hand.

Ureterocele of the lower pole ureter and an ectopic upper pole ureter in a duplex system

We report an unusual case of a ureterocele in a duplex system, which was associated with an ectopic (vulval) upper moiety ureter. This is the second case reported in the literature of a ureterocele arising from the lower pole ureter. Surgical treatment consisted of removal of the upper segment of the kidney and its ureter. The ureterocele was excised and the lower pole ureter was reimplanted in the bladder. At followup 14 years postoperatively the patient was cured and free of urinary infection.

Acquired renal scars in children

To determine the important factors involved in the etiology of renal scarring we studied 37 children with renal scars seen at our hospital since 1965. This is the second largest series reported to date. Children who had neurogenic bladders or any structural abnormalities of the urinary tract other than vesicoureteral reflex were excluded. The study group included 36 girls and 1 boy. The average age at first detection of renal scars was 5.7 years. Acute pyelonephritic episodes, which were treated early and aggressively, infrequently led to renal scarring. However, the initial prolonged or poorly treated episode of acute pyelonephritis was followed invariably by the development of renal scarring. The severity of renal scarring was related to the grade of vesicoureteral reflux (p less than 0.05), although some scars did develop in the absence of reflux. Neither the shape and position of the ureteral orifice nor the ureteral tunnel length correlated with the severity of renal scarring. Treatment with prophylactic antibiotics may have lessened the severity of renal scarring (0.1 less than p less than 0.2) but treatment with reimplantation surgery did not appear to alter the course of renal scarring. This study suggests that the key to the prevention of renal scarring is the early and aggressive treatment of acute pyelonephritis.

Initial results with the Cohen cross-trigonal ureteroneocystotomy

Between January 1976 and December 1980, 109 children with 157 ureters with reflux were seen in consultation. Of these ureters 52 were operated upon using the Cohen cross-trigonal technique, while 105 were followed conservatively. The operative procedure is a complete intravesical ureteral mobilization followed by the creation of a submucosal tunnel across the base of the bladder. Followup studies, including an excretory urogram and voiding cystourethrogram, showed minimal hydronephrosis in 1 ureter and persistent grade I reflux in 1 ureter. Evaluation of these initial results indicates that the Cohen cross-trigonal ureteroneocystotomy is a safe and effective antireflux procedure.

[Continuous plexus anesthesia to improve circulation in peripheral microvascular interventions]

Five patients were demonstrated: one finger replantation, three toe-to-finger transfers and one finger-finger transfer. An axillary plexus catheter was inserted for postoperative sympathetic blockade. This brought about spasmolysis, an increase in the circulation and an increase in the acral systolic blood pressure. Simultaneously an adequate analgesic effect was achieved through the administration of local anaesthesic. The muscle relaxation assisted the immobilisation of the extremity. The improved circulation, the analgesic effect and the suppression of the muscular activity through continuous plexus anaesthesia have a beneficial influence on healing in replanted or transferred digits.

Management of reflux in the myelodysplastic child

More than 75 per cent of the patients with spinal dysrhaphisms followed at our hospital are on intermittent catheterization. A previous report indicated that 62 per cent of 200 children with reflux and a neurogenic bladder either ceased to have reflux or reflux was downgraded while on intermittent catheterization and chronic antibiotics. We report on those children in whom either reflux did not stop while on the program, or who presented with high grades of reflux not amenable to cure by intermittent catheterization. During the last 4 years 25 children (40 ureters) required antireflux surgery. The criterion of repair was persistent reflux of at least grade IIB, associated with recurrent episodes of infection. A modified Leadbetter-Politano technique was used in 5 children (7 ureters) and the Cohen cross-trigonal technique was used in 20 children (33 ureters). A successful result, that is cessation of reflux and no obstruction, was achieved in 96 per cent of the patients. During the last 2 years the Cohen cross-trigonal technique has been used exclusively and there have been no failures. This successful result in 96 per cent of the children with neurogenic bladder indicates that while clean intermittent catheterization should be used primarily to relieve reflux, in a select group of children antireflux surgery should be done and clean intermittent catheterization should be continued.

Hand injuries and disorders. Principles of management for the family physician

Hand injuries and disorders constitute a major cause of disability and time lost from work. Viewed as relatively minor, they are often neglected until permanent disability and restriction of function occur. The first physician to evaluate and treat an injured hand often determines the ultimate outcome of the patient's hand function. Skillful diagnosis and appropriate treatment are necessary. Neglected or mistreated injury may result in significant impairment in a person whose livelihood depends on the skillful, integrated function of both hands.

Radionuclide evaluation of peripheral vascular injuries

Radionuclide techniques have become an important modality for the detection and evaluation of peripheral vascular trauma. The presence of significant vascular injury can be diagnosed using essentially noninvasive procedures. A normal radionuclide angiogram reliably indicates the absence of injury to the major peripheral arterial vessels. An abnormal study suggests that further diagnostic maneuvers may be indicated.

AV anastomosis as a solution for absent venous drainage in replantation surgery

Three cases of replantation in which no conventional venous outflow could be established are presented. A method for obtaining venous outflow is described by using the contralateral artery as a venous pole and anastomosing it to a vein in the proximal stump (with or without a venous graft).

Ureteroceles in children. A simplified and successful approach to management

This review documents the success that we have experienced in treating most ureteroceles that present in children by heminephroureterectomy. If excision of the ureterocele is required, or reimplantation of a ureter other than the ureter obstructed by the ureterocele, this is deferred until the degree of hydronephrosis is reduced or bladder thickening and trabeculation have returned toward normal. In instances where there is function in the upper pole segment obstructed by the ureterocele, ureteropyelostomy has enabled us to preserve renal function by removing the obstructed ureter to permit the ureterocele to collapse.

Clinical application of transcutaneous oxygen measurements in replantation surgery and free tissue transfer

In 65 replantations and 18 free tissue transfers (6 toe-to-thumb and 12 free flaps) transcutaneous oxygen levels were used as a postoperative monitoring system of the microcirculation. In successful replants and successful free tissue transfers an identical pattern of oxygen levels was observed. In failing replants or free tissue transfer, PO2 levels react immediately to changes in microcirculation and these changes in PO2 appear several hours earlier than the clinical symptoms or changes in temperature. This enables salvage operations after circulatory failure caused by thrombosis to be performed before irreversible tissue damage occurs.

Selective finger transposition and primary metacarpal ray resection in multidigit amputations of the hand

In multidigit amputations parts with the most favorable prognosis (cleaner amputation, less crushed, short ischemia time) can be "selectively" replanted in positions most appropriate to providing useful function and cosmetic acceptability, regardless of their anatomic origin. Digits with poor prognosis are not reattached. These principles are applied in four selected cases involving multidigit amputations proximal to the proximal interphalangeal joints in which the least traumatized digits were selectively joined to the more ulnar metacarpal rays; intervening metacarpal shafts were primarily resected to clear the first web space of obstructing bony stumps. The narrowed palmar arch, although weaker, achieves wider palmar span grasp. Fingers in contiguity, although fewer in number, allow improved precision handling, chuck pinch, and cosmetic acceptability.

A retrospective analysis of the use of ureteral stents in children undergoing ureteroneocystotomy

Ureteral reimplantation is used widely for the correction of ureterovesical reflux. To determine the effect of ureteral stents we reviewed the charts of 63 children undergoing ureteral reimplantation for reflux. Of this group 31 patients had the ureterovesical anastomosis stented while 32 did not. Morbidity and operative failure were comparable in both groups. Our results do not support the use of ureteral stents in patients undergoing ureteroneocystotomy for primary ureterovesical reflux.

The effect of preoperative arteriography on vascular endothelium and replant survival in rabbit ears

Although contrast media injected during arteriography is known to decrease microcirculatory blood flow and alter oxygen delivery capacity of the red blood cell, its effect on the vascular endothelium is unknown. This experiment was designed to determine if there were any alterations in arterial or venous endothelial anatomy by scanning electron microscopy and whether replant survival was decreased following arteriography. Our results suggest that when the injection pressure of arteriography is carefully controlled, the contrast media used in this experiment has no effect on vascular endothelium in rabbit ears examined 30 minutes and 24 hours after arteriography. Furthermore, the survival rate of replanted rabbit ears is not affected by arteriography 24 hours prior to replantation. We conclude that preoperative arteriography remains a valuable tool in the planning of free composite tissue transfer but, based on this study, cannot rule out mechanical complications of arteriography that may be deleterious to free tissue transfer.

Management of massively refluxing megaureters

We report on 15 patients with massively refluxing megaureters in 28 renoureteral units. All had a history of urinary tract infections, and 14 were treated with initial vesical drainage. All had ureteral reimplantation, and half of those who initially underwent diversion did not require tailoring. Overall success was 87 per cent.