Robotic-Assisted Bladder Diverticulectomy: Indications, Technique and Outcomes - a Case Series.

PURPOSE: This case series describes the experience and outcomes of multiple Australian surgeons performing robotic-assisted bladder diverticulectomy (RABD), highlighting the procedural effectiveness and safety, for both benign and malignant indications for diverticulectomy. METHODS: Outcomes were analysed from Thirteen experienced Australian urologists who performed RABD between 2016 and 2023. Retrospective analysis was performed on prospectively collected data which included patient demographics, diverticulum characteristics, surgical approaches, and post-operative outcomes. Surgical techniques included the extravesical and intravesical approaches, with the focus on maintaining oncological principles in cases of malignancy. RESULTS: A total of 28 patients underwent RABD, with the majority being male and a mean age of 63.9 years. All surgeons utilised a four port transperitoneal approach and opted for the extravesical dissection of the diverticular neck, one case utilised both extravesical and a trans-diverticular approach. Functional outcomes demonstrated symptomatic resolution in patients with non-malignant diverticula, while oncological outcomes indicated clear margins in 90% of malignant cases. The average length of the procedure was 106 minutes, with minimal blood loss and a mean hospital stay of 2.67 days. Early complications occurred in 14% with the majority Clavien-Dindo grade II . CONCLUSION: Robotic bladder diverticulectomy, predominantly via the transperitoneal extravesical approach, has emerged as a safe, effective, and reliable surgical intervention for both malignant and non-malignant bladder diverticula. The consistent surgical approach and excellent outcomes demonstrated in this case series reinforce the procedure's potential as a safe option, even in the setting of malignancy within a diverticulum.

Autologous Fat Grafting in Breast Augmentation: A Systematic Review Highlighting the Need for Clinical Caution.

BACKGROUND: Autologous fat grafting (AFG) is a breast augmentation method for treating volume and contour abnormalities. This systematic review aims to summarize complications, radiologic safety, volume retention, and patient satisfaction associated with AFG. METHODS: The PubMed, Embase, Google Scholar, Cochrane Central Register of Controlled Trials, Wiley library, clinical key/Elsevier, and EBSCO databases were searched for relevant studies from January of 2009 to March of 2022. Articles describing AFG for breast augmentation were selected based on predetermined inclusion and exclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to, and the study was registered on the International Prospective Register of Systematic Reviews. The Risk of Bias in Nonrandomized Studies of Interventions assessment was used to assess the quality of studies and the risk of bias was measured using the Cochrane Risk of Bias Assessment Tool for Nonrandomized Studies of Interventions. RESULTS: A total of 35 studies comprising 3757 women were included. The average follow-up duration was 24.5 months (range, 1 to 372 months). The overall complication rate was 27.8%, with fat necrosis making up 43.7% of all complications. Average fat volume injected was 300 mL (range, 134 to 610 mL), and average volume retention was 58% (range, 44% to 83%). Volume retention was greater with supplementation of fat with platelet-rich plasma and stromal vascular fraction. The most common radiologic changes were fat necrosis (9.4%) and calcification (1.2%). After 1 year of follow-up, patient satisfaction was, on average, 92% (range, 83.2% to 97.5%). The included studies were of good quality and consisted of a moderate risk of bias. CONCLUSIONS: AFG was associated with an overall complication rate of 27.8%. Additional supplementation of fat with platelet-rich plasma and stromal vascular fraction may improve graft survival. Despite poor volume retention being a persistent drawback, patient satisfaction remains high.

Vasovasostomy: A systematic review and meta-analysis comparing macroscopic, microsurgical, and robot-assisted microsurgical techniques.

BACKGROUND AND OBJECTIVES: Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques. METHODS: Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study's protocol was registered on PROSPERO. RESULTS: This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined. CONCLUSION: Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

Segmental testicular infarction secondary to protein C deficiency.

Protein C deficiency is a rare blood disorder that increases the risk of thromboembolism, resulting in deep vein thrombosis, pulmonary embolisms and strokes. Segmental testicular infarction is also a rare condition with unclear aetiology. This case presents a man in his 50s with protein C deficiency who developed a segmental testicular infarction. The patient was managed conservatively, without surgical intervention. He was monitored with serial ultrasound, which demonstrated progression from normal testis to segmental infarction and eventually resolution. The case highlights that protein C deficiency can cause testicular infarction, and a multidisciplinary approach can help avoid unnecessary surgery with excellent outcomes. Segmental infarction should be considered in patients with pre-existing thrombophilias after excluding malignancy and infection. Conservative management with repeat ultrasonography and follow-up can be appropriate in such cases.

The role of corticosteroid injections in treating plantar fasciitis: A systematic review and meta-analysis.

BACKGROUND: Plantar fasciitis is a recurrent cause of heel pain and is often treated by corticosteroid infections (CSI). The current study reviewed and analysed the role of CSI with platelet rich plasma (PRP), and CSI with extracorporeal shock wave therapy (EWST) for plantar fasciitis treatment. METHODS: PubMed, Medline, Web of Science, Embase, Cochrane, and Google Scholar databases were searched for relevant studies. Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA) guidelines were used to search relevant studies published from infinity to April 2021. The risk of bias was performed using Cochrane Collaboration's tool. GRADE assessment was used for quality of evidence. Data analysis was performed with the use of R software and P < 0.05 was considered statistically significant. CSI was compared with PRP and EWST. RESULTS: Eighteen studies comprising 1180 patients were included in this meta-analysis. When compared to PRP, CSI with lignocaine/lidocaine had significantly higher mean difference on visual analogue scale (VAS) pain scores at 3 months (0.62 [0.13; 1.12], P = 0.01) and 6 months (MD = 1.49 [0.22; 2.76], P = 0.02). At 6 months, VAS scores were higher in the CSI group than the ESWT group (MD = 0.8 [0.38; 1.22], P = 0.1). At 6 months, a significant reduction in the American Orthopaedic Foot and Ankle Score (AOFAS) was observed in the CSI group compared to PRP (MD = - 11.53 [- 16.62; - 6.43], P < 0.0001). CONCLUSION: Patients suffering from plantar fasciitis, PRP achieved better VAS scores compared to CSI at 3 and 6-month follow-up. In addition, ESWT had better VAS score outcomes at 6 months compared to CSI. Regarding AOFAS score, PRP was more efficacious than CSI at 6 months of follow-up. Only through the development of high-quality, large-scale longitudinal studies, will the findings and conclusions of this meta-analysis be strengthened and influence our clinical practice in the treatment of plantar fasciitis. LEVEL OF CLINICAL EVIDENCE: II.

Compartment syndrome as a novel complication of extended spectrum beta lactamase Escherichia coli necrotising soft tissue infection - A case report.

INTRODUCTION AND IMPORTANCE: Necrotising soft tissue infections (NSTI) encompass a group of destructive soft tissue disease processes which can involve skin, subcutaneous tissue, fascia and or muscle, associated with rapid spread along tissue planes and mortality. Clinical presentations include progressive pain, suppuration/necrosis and systemic toxicity with haemodynamic instability. While diagnosis is based on clinical findings it can be augmented with imaging. Treatment is typically in the form of resuscitation, immediate administration of broad spectrum intravenous antibiotics and urgent source control through radical surgical debridement. CASE PRESENTATION: An 82-year-old man presented with left forearm/hand pain and fevers in the context of immunocompromise. Examination found tense swelling of the left volar and dorsal forearm and hand, absent distal pulses with pain and paraesthesia over both surfaces. He underwent surgical debridement with fasciotomy and remained in intensive care with blood cultures revealing ESBL E. coli. CLINICAL DISCUSSION: Compartment syndrome is a rare complication of NSTI and its clinical presentation can obscure early diagnosis. ESBL E. coli is an uncommon pathogen to cause monomicrobial infection and must be accounted for when considering broad spectrum empirical antibiotic cover. CONCLUSION: Review of this case and the literature show a rare presentation of NSTI and highlights the importance of early diagnosis based on even a small index of suspicion. It also shows the key significance rationalisation of antibiotics as soon as practicable, given that even broad spectrum empirical cover can be inappropriate in the context of novel microorganisms, particularly in high risk patients.

High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Unicompartmental Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

Purpose: High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are commonly performed procedures for the treatment of compartmental knee osteoarthritis; however, the optimal procedure remains controversial. We conducted this systematic review and meta-analysis to compare the functional outcomes and assess complications and revision rates between the two techniques. Methods: We searched electronic databases for relevant studies comparing HTO versus UKA for unicompartmental knee osteoarthritis. Continuous data as visual analogue scale (VAS), range of motion, and free walking speed were pooled as mean differences (MDs). Dichotomous data as functional knee outcomes, complications, and revision were pooled as odds ratios (ORs), with 95% confidence interval (CI), using R software for windows. Results: Twenty-five studies involving 8185 patients were included. Meta-analysis showed that HTO was associated with higher risk of complications (OR = 2.47, 95% CI [1.52, 4.04]), poorer functional results (excellent/good) (OR = 0.32, 95% CI [0.21, 0.49]), and greater range of motion (MD = 7.05, 95% CI [2.41, 11.68]) compared to UKA. No significant differences were found between the compared groups in terms of VAS (MD = 0.14, 95% CI [- 0.08, 0.36]), revision rates (OR = 1.30, 95% CI [0.65, 2.60]), and free walking speed (MD = - 0.05, 95% CI [- 0.11, 0.00]). Conclusion: This study showed that UKA achieved fewer complications, better functional outcomes, and less range of motion compared to HTO. No significant differences were detected between HTO and UKA in terms of VAS and revision rate. Treatment options should be personalized to each patient considering factors such as their age, activities of daily living, their body mass index, and severity of osteoarthritis. Level of evidence: II. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00620-9.

Prolactinoma with apoplexy in the context of thrombocytopaenia: A case report.

INTRODUCTION AND IMPORTANCE: Pituitary apoplexy is a clinical syndrome that occurs secondary to abrupt haemorrhage or infarction and can cause a presentation with headache, visual disturbances, and various neurological deficits. Pituitary apoplexy is a rare clinical syndrome that is often misdiagnosed or discovered late in its clinical course due to its relatively nonspecific clinical presentation. CASE PRESENTATION: The case describes patient with a giant prolactinoma which developed haemorrhagic progression in the context of previously undiagnosed coagulopathy from idiopathic thrombocytopaenia. Transcranial (rather than transnasal) surgery was performed for evacuation and debulking. CONCLUSION: The case highlights the management of an exceedingly large adenoma in the context of coagulopathy contributing to rapid clinical progression, as well as a positive clinical outcome in a patient with restored vision and pituitary function.

Novel characterisation of mast cell phenotypes from peripheral blood mononuclear cells in chronic fatigue syndrome/myalgic encephalomyelitis patients.

BACKGROUND: Mast cells (MCs) mediate inflammation through neuropeptides and cytokines, along with histamine and reactive oxygen species (ROS). Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is an illness characterized by an unexplained disabling fatigue with multiple physiological impairments as well as dysregulated cytokine profiles. OBJECTIVE: To determine mast cell phenotypes in isolated human PBMCs, in healthy controls and in CFS/ME patients. Second, determine receptor expression of RAGE and its ligand high mobility group box 1 protein (HMGB1). METHOD: Moderately severe CFS/ME patients (n=12, mean age 39.25 ± SD3.52 years), severe CFS/ME patients (n=6, mean age 43.00 ± SD4.02 years) and healthy controls (n=13, mean age 42.69 ± SD3.87 years) were included in this study. CFS/ME patients were classified according to the 2011 International Consensus Criteria. LSRFortessa X-20 Flow cytometry was used for the identification of phenotypic peripheral mast cell population in PBMCs using an exclusion marker Lin2 cocktail (anti-CD3, anti-CD14, anti-CD19, anti-CD20 and anti-CD56) and inclusion markers (CD117, CD34, FCεRI, chymase, HLA-DR and CD154) following comparative investigation. HMGB1 and soluble RAGE expression in plasma was measured by sandwich ELISA assay. RESULTS: There was a significant increase in CD117⁺CD34⁺FCεRI-chymase- mast cell populations in moderate and severe CFS/ME patients compared with healthy controls. There was a significant increase in CD40 ligand and MHC-II receptors on differentiated mast cell populations in the severe CFS/ME compared with healthy controls and moderate CFS/ME. There were no significant differences between groups for HMGB1 and sRAGE. CONCLUSIONS: This preliminary study investigates mast cell phenotypes from PBMCs in healthy controls. We report significant increase of naïve MCs in moderate and severe CFS/ME patients compared with healthy controls. Moreover, a significant increase in CD40 ligand and MHC-II receptors on differentiated mast cells in severe CFS/ME patients. Peripheral MCs may be present in CFS/ME pathology however, further investigation to determine their role is required.