Hypospadias Surgery. Clinical Aspects and Outcomes

AbstractAim The aim of this thesis was to evaluate the treatment and follow-up of patients undergoing hypospadias surgery at the Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, in an attempt to improve the overall care of these patients. It also aimed to investigate the tissue properties of the urethral plate and deep chordee in hypospadias patients with significant ventral curvature of the penile shaft.Methods Long term follow-up and patient reported outcomes in a cohort of 157 patients were investigated by chart review and a modified hypospadias functional outcome questionnaire. The hypospadias objective scoring evaluation (HOSE) system was used to objectify the results. In addition, 36 patients with secondary hypospadias repairs were analysed via chart review and 10 patients scheduled for orthoplasty during 2014–2015 consented to biopsy of the urethral plate and deep chordee during surgery.Results HOSE analysis indicated that 86% of patients had satisfactory results after primary and secondary hypospadias repair. Overall fistula frequency was 11% after primary repair and post-pubertal follow-up. The HOSE analysis also showed that 82 to 92% of responding patients were neutral or more satisfied with their overall surgical outcomes, appearance, and urinary and sexual function and 90% of responders were satisfied or requested longer follow-up after surgery. In 22% of patients with salvage repairs, additional surgery was required because of complications or shortcomings after re-repairs per our treatment algorithm. All of the biopsy samples from the urethral plate and the deep chordee had similar tissue characteristics and the biopsies confirmed that chordee is a unique tissue entity. In addition, chronic inflammation, a finding not previously reported, was present in every biopsy specimen, with chronic inflammation in the urethral plate manifested as metaplasia in the form of urethritis cystica.Conclusions Our findings show that the long-term, post-pubertal complication rate after hypospadias surgery is low and that a majority of patients have satisfactory results. Patient-reported outcomes indicated that the responding patients were satisfied with their overall long-term surgical/functional outcomes and with the long-term follow-up program. We also found that our treatment algorithm can be applied successfully in cases of secondary hypospadias repairs, provided local tissues are available for flap coverage. In these cases, it is of particular importance to treat all ventral curvature, secondary to chordee and ventral scarring. Thus, many secondary salvage procedures must be handled in two sessions to optimise safety and minimise postoperative complications. Finally, we also report previously undescribed chronic inflammatory activity in tissue samples from urethral plates and deep chordee in patients with hypospadias and ventral curvature, which suggests a possible dynamic feature in this unique tissue entity

Experimental endocarditis in the rat secondary to septic arthritis induced by Staphylococcus aureus

ObjectiveTo develop a modified model for experimental infective endocarditis (IE) in the rat. The goal was to induce a primary infectious focus in the temporomandibular joint (TMJ) of a rat. Hematogenous translocation of the bacteria to the traumatized aortic valve was desired.MethodsCatheterization of the right carotid artery through the aortic valve was performed 7 days after induction of arthritis, which was done by intra-articular injection of glucocorticosteroid (triamcinolone acetonide, 1 mg) and intravenous challenge with 107 CFU Staphylococcus aureus.ResultsTMJ arthritis could be induced by intra-articular triamcinolone acetonide followed by intravenous bacterial challenge. Joints not given glucocorticosteroid were not affected. Only rats with arthritis developed IE subsequent to catheterization as a result of bacteremia generated from the arthritis.ConclusionsThe present model may serve as a complement to the conventional method for induction of IE, in which a high intravenous challenge has to be given. In the present model, IE was instead the result of a continuous low level of bacteremia from an infectious focus in the TMJ. This model mimics the natural development of IE in patients, and may assist as a setting for prophylactic and therapeutic trials

Right ventricular performance after valve repair for chronic degenerative mitral regurgitation.

Our aim was to assess right ventricular (RV) performance after mitral valve repair by use of RV focused echocardiography and to evaluate the influence of elevated pulmonary artery systolic pressure (PASP) on RV recovery

Recognition is not parsing — SPPF-style parsing from cubic recognisers

AbstractIn their recogniser forms, the Earley and RIGLR algorithms for testing whether a string can be derived from a grammar are worst-case cubic on general context free grammars (CFG). Earley gave an outline of a method for turning his recognisers into parsers, but it turns out that this method is incorrect. Tomita’s GLR parser returns a shared packed parse forest (SPPF) representation of all derivations of a given string from a given CFG but is worst-case unbounded polynomial order. The parser version of the RIGLR algorithm constructs Tomita-style SPPFs and thus is also worst-case unbounded polynomial order. We have given a modified worst-case cubic GLR algorithm, that, for any string and any CFG, returns a binarised SPPF representation of all possible derivations of a given string. In this paper we apply similar techniques to develop worst-case cubic Earley and RIGLR parsing algorithms

Temperature effects on incidence of surgery for acute type A aortic dissection in the Nordics

Peer reviewe

Impact of national holidays and weekends on incidence of acute type A aortic dissection repair

Publisher Copyright: © 2022, The Author(s).Previous studies have demonstrated that environmental and temporal factors may affect the incidence of acute type A aortic dissection (ATAAD). Here, we aimed to investigate the hypothesis that national holidays and weekends influence the incidence of surgery for ATAAD. For the period 1st of January 2005 until 31st of December 2019, we investigated a hypothesised effect of (country-specific) national holidays and weekends on the frequency of 2995 surgical repairs for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Compared to other days, the number of ATAAD repairs were 29% (RR 0.71; 95% CI 0.54–0.94) lower on national holidays and 26% (RR 0.74; 95% CI 0.68–0.82) lower on weekends. As day of week patterns of symptom duration were assessed and the primary analyses were adjusted for period of year, our findings suggest that the reduced surgical incidence on national holidays and weekends does not seem to correspond to seasonal effects or surgery being delayed and performed on regular working days.Peer reviewe

Once after a full moon : acute type A aortic dissection and lunar phases

Publisher Copyright: © 2021 The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.OBJECTIVES: Acute type A aortic dissection (ATAAD) is a rare but severe condition, routinely treated with emergent cardiac surgery. Many surgeons have the notion that patients with ATAAD tend to come in clusters, but no studies have examined these observations. This investigation was undertaken to study the potential association between the lunar cycle and the incidence of ATAAD. METHODS: We collected information on 2995 patients who underwent ATAAD surgery at centres from the Nordic Consortium for Acute Type A Aortic Dissection collaboration. We cross-referenced the time of surgery with lunar phase using a case-crossover design with 2 different definitions of full moon (>99% illumination and the 7-day full moon period). RESULTS: The period when the moon was illuminated the most (99% definition) did not show any significant increase in incidence for ATAAD surgery. However, when the full moon period was compared with all other moon phases, it yielded a relative risk of 1.08 [95% confidence interval (CI) 1.00-1.17, P = 0.057] and, compared to waxing moon, only the relative risk was 1.11 (95% CI 1.01-1.23, P = 0.027). The peak incidence came 4-6 days after the moon was fully illuminated. CONCLUSIONS: This study found an overrepresentation of surgery for ATAAD during the full moon phase. The explanation for this is not known, but we speculate that sleep deprivation during full moon leads to a temporary increase in blood pressure, which in turn could trigger rupture of the aortic wall. While this finding is interesting, it needs to be corroborated and the clinical implications are debateable.Peer reviewe

Outcome after surgery for acute type A aortic dissection with or without primary tear resection

Background: The outcome in patients after surgery for acute type A aortic dissection without replacement of the part of the aorta containing the primary tear is undefined.Methods: Data of 1122 patients who underwent surgery for acute type A aortic dissection in eight Nordic centers from Jan 2005 to Dec 2014 were retrospectively analyzed. The patients with primary tear location either unfound, unknown, not confirmed or not recorded (n=243, 21.7%) were excluded from the analysis. The patients were divided into two groups according to whether the aortic reconstruction encompassed the portion of the primary tear (TR group, n=730) or not (TNR group, n=149). The restricted mean survival time ratios adjusted for patient characteristics and surgical details between the groups were calculated for all-cause mortality and aortic reoperation-free survival. The median follow-up time was 2.57 (inter-quartile range 0.53-5.30) years.Results: For the majority of the patients in the TR group, the primary tear was located in the ascending aorta (83.6%). The reconstruction encompassed both aortic root and the aortic arch in 7.4% in the TR group as compared with 0.7% in the TNR patients (PConclusions: Primary tear resection alo</p

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry

ObjectivesTo describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection.MethodsA retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation.ResultsThe median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease.ConclusionsType A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.</p