Predictive Factors for the Peri-operative Outcome of Ureteroscopic Lithotripsy for Proximal Ureteric Stones.

BACKGROUND: Proximal ureteric stones are considered one of challenging location for lithotripsy using semirigid ureteroscopes. Aim of the study was to assess clinical and radiological characteristics associated with outcome of lithotripsy using semirigid ureteroscope for proximal ureteric stones. METHODS: Prospective observational study was done on patients who underwent semirigid ureteroscopic lithotripsy for proximal ureteric stone. Stone and ureteral mormphomeric parameters were documented from computed tomography urogram. Stone free status and complication rates were studied. To determine predictive factors for outcomes, multivariate regression analysis and receiver operative curve were used. RESULTS: One hundred patients were included in study. Demographic characteristics, stone size, density and mode of lithotripsy had no impact on stone free rate or complications. The mean ureteral wall thickness(p = 0.002), distance of stone from pelvi-ureteric junction(p = 0.005), degree of hydronephrosis(p = 0.0001) and peri-ureteric fat stranding (p = 0.038) were found to have significant association with stone free rate on univariate analysis. On multivariate analysis, mild hydronephrosis(p = 0.003) and distance of stone from pelvi-ureteric junction(p = 0.022) were significant for stone free rate. CONCLUSIONS: Mean ureteral wall thickness, stone distance from pelvi-ureteric junction, presence of peri-ureteric fat stranding and hydronephrosis affect stone free rate on univariate analysis. On multivariate analysis for stone free rate, stone distance from pelvi-ureteric junction and mild hydronephrosis were significant. There was no significant impact of any stone or ureteral morphometry on complication rate.

Prostatic Urethral Length as a Predictor for Surgery in Benign Prostatic Hyperplasia.

BACKGROUND: Benign prostatic hyperplasia is associated with structural and morphological changes including elongation of prostatic urethral length. The aim of our study was to assess whether prostatic urethral length could predict need of surgery in patients with benign prostatic hyperplasia. METHODS: This prospective observational study was conducted over a 12-months duration. All the patients who presented with lower urinary tract symptoms secondary to benign prostatic hyperplasia were evaluated with International Prostate Severity Score, serum Prostate Specific Antigen, Transrectal Ultrasound was done to measure prostatic urethral length, prostate volume, Intravesical prostatic protusion and Post-void Residual Urine. Patients not responding to medical treatment and complications secondary to benign prostatic hyperplasia underwent surgery. Logistic regression analysis was performed to identify risk factors associated with surgery. RESULTS: A total of 153 patients were included in the study. Eighty-three (54.2%) patients underwent surgery during the study period. Prostate volume, intravesical prostatic protrusion, post-void residual volume, serum prostate specific antigen, and prostatic urethral length were significantly higher in the surgical group. The mean prostatic urethral length in the surgical group was 39.47 + 10.2 mm and in the nonsurgical group was 26.20 + 6.72 mm (p <0.0001). According to the ROC curve-based prediction of surgery, the area under the curve for PUL was 0.866 and the best cutoff value was 31.5mm (81% sensitivity and 84.3% specificity). CONCLUSIONS: BPH patients with longer PUL may require surgical management. PUL measured by TRUS may be a predicting factor for the need of surgery in BPH Keywords: Benign prostatic hyperplasia; lower urinary tract symptoms; prostatic urethral length.

How Safe Is Reverse Sural Flap?: A Systematic Review.

Background: Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap. Methods: A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap. Results: A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed). Conclusions: Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.

Plastic Surgical Procedures for Lower Limb Reconstruction at a Tertiary Hospital in Nepal.

BACKGROUND: This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. METHODS: In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). CONCLUSIONS: Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries.

BACKGROUND: Free tissue transfer is one of the most important and essential techniques in reconstructive surgery. The underlying complexity, steep learning curve, high cost, and fear of failure make it very difficult to establish as a regular service in developing countries such as Nepal. METHODS: A retrospective cohort study design was used to analyze the challenges with and opportunities for reconstructive surgery in Nepal. Medical records were reviewed for patient demographics, indications, types of free flaps, hospital stay, complications, and involvement of a microsurgery teaching workshop. RESULTS: A total of 16 microsurgical workshops were carried out by 3 international organizations over the study period (2007-2017). Altogether 108 free flaps in 103 subjects were reviewed during the study period at different hospitals of the Public Health Concern Trust-NEPAL (phect-NEPAL) and National Trauma Center. Of 103 patients, 60 were males and 43 were females with an average age of 34.5 years (range, 8-73 years). The most common indications for microsurgical reconstruction were tumor, trauma, and burns. Radial artery forearm flap, anterolateral thigh flap, and free fibular flap were the most common types of flaps. Ten different types of flaps were performed. Four cases needed more than 1 flap; one of them needed 3 flaps. Flap success rate approached 90%. Four patients died in the hospital postoperatively. CONCLUSION: Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.

Clinical Epidemiology of Acute Burn Injuries at Nepal Cleft and Burn Centre, Kathmandu, Nepal.

BACKGROUND: Burn injury is a global health problem mainly occurring in developing countries. The Nepal Cleft and Burn Centre at Kirtipur Hospital, Kathmandu, has been providing the acute burn care since 2013 with 7 intensive care unit beds, 30 general beds, and 2 dedicated operating rooms. A similar descriptive study was performed in this center in 2014. These studies will be helpful for developing prevention strategies and monitoring the progress in the standard of care of acute burn patients. METHOD: This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1, 2015 to December 31, 2016. RESULTS: There were a total of 567 patients who came from 63 of 75 total districts of Nepal. Two hundred ninety-six (52.2%) patients were females and 271 (47.8%) were males. Two thirds of the patients were young adults. Most of the injuries occurred inside the house (72.1%). Flame burn was the most common mode of injury (66%) followed by scald (21.6%). Only 64 (11.3%) patients arrived on the same day of the injury. The longest time elapsed was 60 days with a median of 4.3 days. Range of total body surface area (TBSA) involved was 1% to 95%. The mean and median TBSAs were 25% and 15%, respectively. Range of hospital stay was 1 to 105 days with a median of 13.3 days.A total of 448 surgical procedures were performed in 384 patients (67.7%). A total of 110 (19.4%) patients died at the hospital. Only 13 patients (3%) survived deep burn injury involving 40% or more TBSA with either cadaveric skin allograft or with skin allograft from the live relatives. CONCLUSIONS: The outcome of burn injuries in Nepal is very poor. Children and females are at high risk. There is a lack of knowledge about burn prevention, proper first aid, and skin donation among the Nepalese population. Delay in presentation and extensive burns are poor prognostic factors. Awareness programs about the proper first aid and the need of a skin bank has to be done to improve the burn scenario in Nepal. Availability of allograft can increase the chances of survivability of patients with extensive burns in Nepal.

Erratum to: Epidemiology of burn injuries in Nepal: a systemic review.

[This corrects the article DOI: 10.1186/s41038-017-0075-y.].

Epidemiology of burn injuries in Nepal: a systemic review.

Burn is a global public health problem associated with significant morbidity and mortality, mostly in low- and middle-income countries. Southeast-Asian countries share a big burden of burn injuries, and Nepal is not an exception. We performed a systemic review to examine the epidemiological characteristics of burn injures in Nepal. Relevant epidemiological studies were identified through systemic search in PubMed, EMBASE, and Google Scholar. Reference lists from relevant review articles were also searched. Studies were included if they meet our selection criteria. Eight studies were included in our systemic review. Most of the burn victims belong to the working age group between 15-60 years old. Flame burns were found to be the most common cause of burn injury followed by scald burns, whereas scald burns were the most common cause of burn injury among the pediatric population. Most patients sustained less severe burn injuries, with home being the most common place of burn injury. The average hospital stay among the burn victims ranged from 13 to 60 days. Mortality among the burn victims ranged from 4.5 to 23.5%, with highest mortality among the flame burn patients. Developed nations have significantly reduced the burn incidence through effective intervention program. Although, burn injuries are the leading cause of morbidity and mortality in Nepal, effective intervention programs are lacking due to the limited epidemiological data related to burn injuries. Further large scale research is imperative to investigate the problem and assess the effectiveness of an intervention program.

Age of individuals undergoing cleft lip and cleft palate surgeries in Nepal.

INTRODUCTION: Timely repair of cleft lip and palate maximises the benefits of surgery. Developing countries have large number of adults with unrepaired clefts. The impact of a cleft program can be determined by observing the trends of lower age at surgery. Public Health Concern Trust, Nepal has been providing a comprehensive nationwide cleft service since 1999. This study was conducted to see any change in the age at surgery. METHODS: A retrospective cross sectional study was conducted to analyse the data of all the individuals' age at primary cleft surgery from July 1999 to June 2010. Mean and median age of individuals as well as the proportion of individuals operated on at the right age in different years were calculated and compared. RESULTS: The median age for cleft lip surgery decreased from 100 to 24 months. Similarly the median age for cleft palate surgery decreased from 70 to 28 months. Proportion of surgeries carried out in the recommended age also increased. A change in the policy of the program reaching out to more remote areas and removing the age barrier for surgery resulted in older adults receiving surgery and increased median age especially for cleft palate repairs. CONCLUSIONS: A nationwide cleft program for a decade had a small impact on age at surgery. There are still many individuals who are missing the ideal age for surgery. The program needs to reach more remote areas. This information will be useful for governmental as well as non-governmental organizations working in the area of clefts.