Overview of Urethral Reconstruction by Tissue Engineering: Current Strategies, Clinical Status and Future Direction

BACKGROUND: Urinary tract is subjected to a variety of disorders such as urethral stricture, which often develops as a result of scarring process. Urethral stricture can be treated by urethral dilation and urethrotomy; but in cases of long urethral strictures, substitution urethroplasty with genital skin and buccal mucosa grafts is the only option. However a number of complications such as infection as a result of hair growth in neo-urethra, and stone formation restrict the application of those grafts. Therefore, tissue engineering techniques recently emerged as an alternative approach, aiming to overcome those restrictions. The aim of this review is to provide a comprehensive coverage on the strategies employed and the translational status of urethral tissue engineering over the past years and to propose a combinatory strategy for the future of urethral tissue engineering. METHODS: Data collection was based on the key articles published in English language in years between 2006 and 2018 using the searching terms of urethral stricture and tissue engineering on PubMed database. RESULTS: Differentiation of mesenchymal stem cells into urothelial and smooth muscle cells to be used for urologic application does not offer any advantage over autologous urothelial and smooth muscle cells. Among studied scaffolds, synthetic scaffolds with proper porosity and mechanical strength is the best option to be used for urethral tissue engineering. CONCLUSION: Hypoxia-preconditioned mesenchymal stem cells in combination with autologous cells seeded on a prevascularized synthetic and biodegradable scaffold can be said to be the best combinatory strategy in engineering of human urethra.

Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon’s preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Follicular thyroid cancer with sternal metastasis - challenges and outcomes

Sternal metastasis from differentiated thyroid carcinoma (DTC) is rare and presents a conundrum for surgeons. We present a lady diagnosed with follicular thyroid carcinoma and sternal metastasis who underwent thyroidectomy, sternectomy and sternoplasty with titanium mesh and acrylic plate. She developed a surgical site infection, of which multiple conservative approaches were attempted. She eventually required removal of the implant. Closure of sternal defect was completed with bilateral pectoralis major advancement flaps. This article highlights a series of complications faced during the course of treatment and how they were managed in a tertiary healthcare centre.

Amputation and non-functioning limb salvage: cultural stigma of limb loss

Amputation is usually the last resort for treatment of non-salvageable limbs due to various indications such as trauma, infection and malignancy. However, some patients still refuse surgery and reconstruction. Instead, they insist on keeping their limbs despite knowing the negative consequences including a limited or non-functioning limb. We present three cases who refused amputations: The first was a nine-year-old boy involved in a motor vehicle accident [MVA], with a left femoral midshaft open grade IIIb fracture; the mangled extremity severity score [MESS] was five. The second was a 16-year-old girl sustained a left leg crush injury, a fractured left fibula and an injury to the anterior tibial artery following an MVA; her MESS was 12. The third was a 60-year-old left-handed tractor driver presented with a fiveyear history of a slowly enlarging fungating growth over the dorsum of his left hand; biopsy confirmed basal cell carcinoma [BCC]. We explore the cultural and religious reasons behind this stigma of amputation in a multiethnic community. It will help clinicians to manage these challenging situations according to the principles of medical ethics

Anatomical variants of the superficial temporal artery in patients with microtia: a pilot descriptive study / 대한해부학회지

Superficial temporal artery (STA) based pedicled fascial flap plays a pivotal role in ear reconstruction for microtia patients. There is paucity of literature on the anatomy of the STA in microtia patients. The present study aimed to describe any possible anatomical variations seen in the STA of patients afflicted with microtia. Pre-operative carotid computer tomographic angiography images of patients under the microtia database of Plastic and Reconstructive Surgery Unit at a tertiary medical centre were selected and 3-dimensionally reconstructed. Measurements were made on the 3D reconstructed computed tomographic angiography images of the STA on both the sides of the microtic ear and the non-microtic ear to assess its various anatomical parameters. We managed to obtain a total of 39 computed tomographic angiography images of STAs for analysis. There was a significant difference in the number of main branches of STA between the two groups (P=0.006). The proportion of ears with 2 main branches was higher in the non-microtia group (89.5%) compared to the microtia group (45.0%). A significant difference was found in the STA diameter between the two groups (P=0.012). The mean diameter of STA in the non-microtia group was larger by 0.4 mm. Furthermore, the median angle of STA was larger on the side of the non-microtic ears compared to that of microtic ears by 24.5°, with a P-value of 0.011. The results of the study may be of clinical importance while planning and performing ear reconstructive surgeries using STA based pedicled fascial flaps.

Staged reconstruction of a tessier number 4 facial cleft

Tessier number 4 cleft is an extremely rare facial cleft. We report a case of Tessier number 4 facial cleft recently managed in our center. The approach to facial clefts is multi-disciplinary and may differ between centers. Multiple surgical interventions are required as well as a good psychosocial support. The child underwent a craniofacial reconstruction at 6 months of age, followed by a left macrostomia repair 9 months later and transcranial correction of the right orbital dystopia with eyelid reconstruction

Reconstruction Options Following Wide Excision of Basal Cell Carcinoma of the Face

Basal cell carcinoma is the commonest skin malignancy diagnosed in Malaysia. Surgery is the recommended treatment of choice with the lowest failure rate provided a clear margin is obtained. However, the defect may be too large to be repaired primarily. Formal reconstruction using grafts and flaps should be done to achieve the optimal aim of maintaining the integrity, function and cosmetic patient outcome. Three reconstructive methods are described in this series to restore the facial defect following the wide local excision. The procedures described were peri-alar crescentic advancement flap, nasolabial rotational flap and full thickness skin graft using supraclavicular skin. This series highlights the usage of the procedures based on solid foundation and principles, without compromising the desired outcomes for the patient.

What Lurks Beneath: Lacrimal Gland Adenocarcinoma Dedifferentiation to Sarcomatoid Carcinoma

This was a case of a young lady presenting with 10 year history of a mass in the right eye. It was found to be an adenocarcinoma of the lacrimal gland from histopathological biopsy. She underwent wide excision, orbital exenteration and reconstruction with a free rectus abdominis flap. Unfortunately, she had a tumour recurrence which was not controlled by radiotherapy and a second excision. The behavior of the tumour was aggressive, resulting in widespread metastases. She passed away within a year of her presentation. Of note, the histopathology report from the second excision turned out to be sarcomatoid carcinoma. This is described in the literature as dedifferentiation, or high grade transformation (HGT). Occurrence of dedifferentiation in salivary gland tumours is well-established, but not as well-described in lacrimal gland tumours. In this case, there was a severely delayed presentation of a lacrimal gland adenocarcinoma in a young person, which underwent dedifferentiation into a sarcomatoid carcinoma. This phenomena is associated with aggressive tumour biology behavior and poor prognosis, despite surgery and radiotherapy.

Penile Augmentation with Resultant Foreign Material Granuloma and Sequalae

Throughout history, a proportion of men appear to correlate penis size and dimensions directly with physical fitness and sexual prowess. Foreign materials, such as paraffin oil, paraffin balm, mineral oils, and silicone, have been used to promise an improvement in penile shaft contour and dimensions. These materials are injected directly into the penis; inducing granuloma formation to achieve increased penis length and girth. However, the result is a severely disfigured and swollen penis, which cannot achieve erection. Local complications of penile lipogranuloma include infection, ulceration, local migration, and cavernosal invasion; leading to functional impairment. Meanwhile, systemic complications include foreign body embolization, organ infarct, and death. Penile lipogranuloma is best treated surgically. Granulomatous skin needs to be completely excised; wound closure with a scrotal skin flap, Cecil’s inlay operation and split thickness skin graft commonly used options. Our case series has shown that penile lipogranuloma, induced by subcutaneous foreign body injections into the penile shaft, and its subsequent adverse outcomes to patients and their partners.