Robotic reconstruction of necrosed ileal ureter: Technical challenges, intra-operative difficulty, and learning points.

This video explores the challenges faced during a re-do robotic intra-corporeal ileal ureter reconstruction in a previously operated case. A 24-year-old woman presented with a 12-cm long stricture after robotic ileal ureter replacement surgery. A proper preoperative evaluation in the form of ureteroscopy and a nephrostogram is essential and the key steps include adhesiolysis, identification of the necrotic ileal ureter, and meticulous dissection. A 13-cm long segment of the ileum was isolated and was anastomosed to the renal pelvis and the bladder. The surgery lasted for 420 min with 300 ml of blood loss. Post-operatively, the patient recovered well and had a normal drainage with no complications at 1-year of follow-up. The factors such as a broad mesentery, a tension-free anastomosis, and avoiding the twisting of the pedicle are crucial for success of robotic ileal ureter replacement surgery.

A primer on twistronics: a massless Dirac fermion's journey to moiré patterns and flat bands in twisted bilayer graphene.

The recent discovery of superconductivity in magic-angle twisted bilayer graphene (TBLG) has sparked a renewed interest in the strongly-correlated physics ofsp2carbons, in stark contrast to preliminary investigations which were dominated by the one-body physics of the massless Dirac fermions. We thus provide a self-contained, theoretical perspective of the journey of graphene from its single-particle physics-dominated regime to the strongly-correlated physics of the flat bands. Beginning from the origin of the Dirac points in condensed matter systems, we discuss the effect of the superlattice on the Fermi velocity and Van Hove singularities in graphene and how it leads naturally to investigations of the moiré pattern in van der Waals heterostructures exemplified by graphene-hexagonal boron-nitride and TBLG. Subsequently, we illuminate the origin of flat bands in TBLG at the magic angles by elaborating on a broad range of prominent theoretical works in a pedagogical way while linking them to available experimental support, where appropriate. We conclude by providing a list of topics in the study of the electronic properties of TBLG not covered by this review but may readily be approached with the help of this primer.

Outcomes of bladder neck botulinum toxin injection for female primary bladder neck obstruction-does subjective improvement correlate with an objective assessment?

INTRODUCTION AND HYPOTHESIS: Common options for management of primary bladder neck obstruction (PBNO) in women include medications and surgical treatment. Less invasive treatment such as bladder neck botulinum toxin injection can be an alternate therapy in patients with failed conservative management. In this study, we describe the subjective and objective outcomes, patient satisfaction, and willingness for repeat treatment with bladder neck botulinum toxin injection in females with PBNO. METHODS: A retrospective analysis of ten female PBNO patients managed with bladder neck botulinum toxin injection was performed. Subjective parameters were quantified with symptom assessment, International Prostate Symptom Score (IPSS), and Quality of life (QoL) score. Objective parameters were assessed with maximum flow rate (Qmax) in uroflowmetry and postvoid residual (PVR). RESULTS: The mean pre-treatment IPSS, QoL score, Qmax, PVR was 24.2 ± 5.0, 4.8 ± 0.63, 5.73 ± 3.18 ml/s, and 210 ± 66 ml, respectively. Seven of the ten patients subjectively improved (IPSS 12.9 ± 9.6, QoL2.9 ± 1.6, p < 0.05). Three patients improved objectively (mean Qmax 17.3 ± 2.7 ml/s, PVR 42.7 ± 7.5 ml, p < 0.05). Three patients accepted repeat botulinum toxin injection. Three patients who showed no improvement underwent bladder neck incision with resolution of symptoms. CONCLUSION: Botulinum toxin can be an intermediary therapy in female patients with PBNO who want a minimally invasive procedure.

Undiagnosed spontaneous oesophageal rupture presenting as right hydropneumothorax.

Spontaneous oesophageal rupture has been a known ailment with a high morbidity and mortality. Various factors contribute to its predisposition such as preexisting oesophageal diseases, increased intraluminal pressure, neurogenic causes, and iatrogenic-commonest being instrumentation. We present the case of a 26-year-old male with features of right hydropneumothorax for which an intercostal chest drain (ICD) was inserted that yielded turbid fluid with suspicion of it being gastric contents. With a diagnosis of diaphragmatic hernia and gut/bowel injury caused due to intercostal drain, the patient underwent emergency exploratory laparotomy. No abnormality was detected and possibility of oesophageal injury/rupture was contemplated though ruled out on investigations. The patient improved with medical treatment of empyema and discharged. The patient was lost to follow-up until after a year the patient reported to surgery OPD with complaints of dysphagia. A barium swallow revealed thoracic oesophageal benign stricture thus confirming our suspicion of spontaneous oesophageal rupture that had occurred a year ago. Knowledge about atypical presentations of oesophageal rupture is important so as to be more aware of this possibility.