Akshay Pratap

Complex Posterior Urethral Disruptions: Management by Combined Abdominal Transpubic Perineal Urethroplasty

PURPOSE We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. MATERIALS AND METHODS From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram. RESULTS There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence. CONCLUSIONS Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.

Transorbital Orbitocranial Penetrating Injury due to Bicycle Brake Handle in a Child

Transorbital orbitocranial penetrating injuries (TOPI) are relatively rare and can be caused by a variety of unusual objects. Diagnosis of TOPI should be based on a detailed history and evaluation of available investigations as the penetrating injury may be overlooked. In the present case, a child sustained a penetrating injury with the brake handle of a bicycle due to the accidental fall of the bicycle on him and was managed conservatively.

Application of a plain abdominal radiograph transition zone (PARTZ) in Hirschsprung's disease

BackgroundA standard contrast enema for Hirschsprungs disease can sometimes be inconclusive in delineating a transition zone especially in neonates and infants. The aim of this study was to determine the utility and diagnostic accuracy of a plain abdominal radiograph transition zone (PARTZ) in predicting the level of aganglionosis.MethodsA prospective observational study of neonates and infants with biopsy proven Hirschsprungs disease was carried out from March 2004 through March 2006. All patients underwent a plain abdominal radiograph and a contrast enema followed by a rectal biopsy. The transition zone on a plain radiograph (PARTZ) and contrast enema (CETZ) were compared with operative and pathology reports. Results were analyzed by chi square test and expressed as their p values and 95% confidence intervals.ResultsPARTZ and CETZ suggestive of Hirschsprungs disease was seen in 24(89%) and 18(67%) patients respectively. The PARTZ and CETZ matched with the pathologic level of transition zone in 22(92%) and 13(72%) patients, p = 0.001, 95% CI (-1.87 to -0.79). In the 9 (33%) patients in whom contrast enema failed to reveal a transition zone, PARTZ was seen in 6/9(66%) patients and correlated with the pathological level of aganglionosis in 4/6(67%) patients, p = 0.001 95% CI (-1.87 to -0.79). The overall accuracy of PARTZ and CETZ was 96% and 84% respectively, p = 0.008, 95% CI (-6.09 to -3.6).ConclusionA plain abdominal radiographic transition zone is reliable in predicting the level of transition zone in cases of inconclusive contrast enema. It may be particularly helpful developing countries where laparoscopic techniques are not available to accurately identify the transition zone.

Inflammatory Myofibroblastic Tumor of the Abdominal Wall Simulating Rhabdomyosarcoma: Report of a Case

We report the case of a 6-year-old boy with a progressively enlarging mass in the anterior abdominal wall. Computed tomography showed an intensely enhancing heterogeneous lesion arising from the anterior abdominal wall muscles with intraperitoneal extension. Based on the location of the tumor and the radiological findings we made a provisional diagnosis of rhabdomyosarcoma. However, the findings of fine-needle aspiration and Trucut biopsy were inconclusive for malignancy. We performed complete excision of the mass, including the involved left costal segment. Microscopically, the tumor was composed mainly of spindle-shaped cells without malignant features, and immunohistochemical analysis revealed positive staining for actin. These findings confirmed a diagnosis of an inflammatory myofibroblastic tumor (IMT). To our knowledge, this is the first case report of an extrapulmonary IMT arising from the anterior abdominal wall.

Giant cavernous hemangiolymphangioma of the bladder without cutaneous hemangiomatosis causing massive hematuria in a child

We report the first case of cavernous hemangiolymphangioma of the urinary bladder without cutaneous hemangiomatosis. A 5-year-old boy was admitted for investigation of a 2-month episode of gross hematuria accompanied by lower abdominal pain. Radiological investigations revealed a solid enhancing mass at the dome of the bladder with associated low-flow lesion in the posterolateral wall of the bladder. Physical examination did not show any cutaneous vascular malformations. A differential diagnosis of hemangioma or rhabdomyosarcoma bladder was made, but fine-needle aspiration cytology did not reveal any malignant cells. At surgery, a red, wide-based, nodular tumor was found on the dome of the bladder and extending to the base and lateral walls. Partial cystectomy and excision of the cystic lymphangioma was performed. Histological examination of the resected specimen showed it to be a cavernous hemangiolymphangioma. The postoperative course was uneventful and no recurrence was seen after 8 months.

One year of neurosurgery in the eastern region of Nepal

BACKGROUND This article briefly discusses about the present status, future strategies, and perspectives of neurosurgery in the eastern region of Nepal. METHODS B.P. Koirala Institute of Health Sciences, Dharan, Nepal, is the only tertiary referral center responsible for patient care as well as training of postgraduate students and paramedical staff including health care workers in the eastern region of Nepal. We analyzed the data from January 2006 to January 2007 regarding patient care and their outcomes. At the same time, we also evaluated our limitations regarding resources and their impact on patient care. Strategies are suggested to overcome the barriers to establish effective neurosurgical centers in developing countries. RESULTS At present in the BPKIHS, neurosurgical facilities are being provided as a specialty unit in the department of surgery. From January 2006 to January 2007, a total 1120 patients were treated for different neurological and neurosurgical conditions. At present, there are 8 beds allotted to neurosurgical services in the general surgery ward. In addition, there are 8 ICU beds catering to the needs, including neurosurgery, of the hospital. No vascular, epilepsy surgery or functional neurosurgery has been performed due to lack of resources. The only imaging facility for neurosurgery that is available in the hospital is CT scan. CONCLUSIONS The study concludes that in a developing country, the neurosurgical unit can be structured in a manner that will fulfill most of the objectives required for better clinical outcome. This structured program may also benefit substantially in training health professionals as well.

Cerebellar Abscess following Mastoidectomy for Chronic Otitis Media

Chronic otitis media although rare in developed countries is still a major problem in the developing countries. If untreated, it can lead to life-threatening intracranial complications. In the available literature the incidence and risk factors for cerebellar abscess following mastoidectomy is not known. In this case we would like to emphasize that CT scan before mastoidectomy is not possible in all the cases particularly in developing countries. There is a need to find the factors that will make one suspect the possibility of concurrent intracranial lesions and which will identify the patients prone to intracranial complications.

Doppler Study of Splanchnic Hemodynamics in Hirschsprung’s Disease

Background: Doppler studies of splanchnic vessels have demonstrated alteration in blood flow in bowel obstruction and strangulation. The aim of this study was to evaluate hemodynamic changes in celiac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) using pulsed Doppler sonography (PDS) in Hirschsprung’s disease. Material and Methods: Fasting splanchnic flowmetry of CA, SMA, and IMA arteries was performed using PDS preoperatively in 13 patients with Hirschsprung’s disease and 13 healthy age- and sex-matched controls. Diagnostic workup for Hirschsprung’s disease included a barium enema and a rectal biopsy. A primary transanal pull through was performed if the transition zone was at rectosigmoid or midsigmoid. Doppler studies were repeated on the 1st and 7th postoperative day under similar conditions. Mean flow velocity (Vmean) and the pulsatility index (PI) of the three major vessels was measured. Results: Patients with Hirschsprung’s disease showed increased blood flow velocities in CA, SMA, and IMA (p < 0.001), an increased resistance to blood flow in IMA (p < 0.001) and a decreased resistance to blood flow in CA and SMA (p < 0.005 and p < 0.001, respectively). The blood flow velocity for IMA normalized after resection of the aganglionic segment (r = 0.41, p < 0.005, 95% CI: 45.4–52.7). Conclusions: Hirschsprung’s diseaseis associated with alterations in splanchnic vessel hemodynamics which are reversible after corrective surgery. Doppler studies may play an important role in the assessment of bowel function after surgery.

Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

BackgroundThis report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).MethodsTwenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).ResultsThe patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.ConclusionThe technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARMs without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.

Infected Retroperitoneal Cystic Lymphangioma Masquerading as Psoas Abscess

A 2-year-old male is described who presented with fever, fixed flexion deformity of the right hip and a tender mass in the right iliac fossa. A clinical diagnosis of psoas abscess was made. Abdominal ultrasound was suggestive of an echogenic retroperitoneal cyst but could not accurately determine the nature of the cyst. A contrast CT scan showed a retroperitoneal cyst. At laparotomy, a large retroperitoneal cyst containing turbid fluid was found and was excised completely. Histopathological examination was suggestive of cystic lymphangioma. Clinical presentation of retroperitoneal lymphangioma may be variable and misleading, therefore complex imaging studies are necessary in the evaluation of this condition.