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Anomalous origin of the right pulmonary artery from the ascending aorta is a rare congenital lesion with a high mortality and morbidity if early diagnosis is not made and correction is not undertaken. We describe the repair of such a lesion using a double-trapdoor technique of pulmonary artery reimplantation.
The problem of sizing the graft, annulus, and left ventricular outflow tract for the David reimplantation type of aortic valve preserving procedure remains a concern, particularly in patients with Marfan syndrome. To resolve this issue, a modified method used in over 20 patients is described of doing the repair around a Hegar's dilator. In essence, the size chosen is according to the patient's normalized annular size based on body surface area. This technique also creates a neosinus in the root.
From January, 1970, through December, 1984, nineteen infected or eroded pacemaker units were reimplanted in 17 patients. Characteristics of the patients, types of infecting organisms, surgical management, and complications are described. Optimal treatment of the infected generator pocket requires explantation of the generator unit with utilization of the in situ leads for pacing by an external-demand pacemaker unit. The generator unit is sterilized, and new leads are placed with relocation of the pocket. The old leads are then removed. This technique has been used safely and with excellent results for the past fourteen years.
Combining a subclavian flap procedure and reimplantation of the distal subclavian artery into the left carotid artery was used in 2 patients with recurrent coarctation of the thoracic aorta. One of the patients was 12 years old and the other, 6 years old. The operation has several advantages. (1) It is very efficient in relieving recurrent gradients. (2) The use of prosthetic material is avoided. (3) Minimal dissection is required. (4) It prevents subsequent subclavian steal syndrome and long-term ischemia of the left upper limb.
We describe a technique to relieve tension on the reimplanted right coronary button during aortic root replacement. A hood is fashioned from autogenous aorta or pericardium to provide a funnel inflow to the coronary ostium. The technique can be used either electively or as a rescue maneuver in the event of right ventricular ischemia.
PURPOSE: The authors studied the preoperative Technetium 99m-dimercaptosuccinic acid renal scan (DMSA) of patients undergoing unilateral vesicoureteral antireflux surgery to compare the amount of renal scarring between the refluxing and the contralateral renal units. They sought to determine whether postoperative contralateral vesicoureteral reflux was preexistent or new onset. METHODS: Sixty-eight patients who underwent unilateral vesicoureteral antireflux surgery and had preoperative DMSA and postoperative voiding cystourethrography (VCUG) examinations were studied. Preoperative DMSA results were analyzed to determine the amount of renal scarring in each kidney. RESULTS: Sixty-four (94.1%) ipsilateral refluxing renal units had renal scars. Of the 68 contralateral renal units, scars were noted in 28 (41.2%). The rate of nonscar was 4 of 68 (5.9%) in reflux kidneys, which was significantly lower than 40 of 64 (62.5%, excluding 4 with a history of resolved reflux) in nonreflux kidneys (P<.001). Of 40 contralateral nonscarred kidneys, 1 of 40 (2.5%) had subsequent reflux, which was significantly lower than 5 of 28 (17.9%) of scarred kidneys (P<.005). Six patients (8.8%) had contralateral reflux, and 1 of them had a history of resolved reflux. Of the 6 contralateral kidneys with severe scarring involving 3 poles or contracted, 4 of 6 (66.7%) had subsequent reflux. CONCLUSIONS: Scar in the contralateral kidney seen on DMSA scan seems to predict contralateral reflux after unilateral antireflux surgery. The contralateral reflux may be preexistent. Postoperative VCUG should be performed routinely for patients who have contralateral renal scars. In patients with a history of contralateral reflux or severe contralateral renal scar, simultaneous contralateral ureteral reimplantation should be considered.
Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% (n = 60), occlusion rate 1.6% (n = 1), and incidence of threadlike arteries 4.9% (n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% (n = 57), occlusion rate 6.5% (n = 4), and the incidence of threadlike arteries 8% (n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% (n = 58) and the occlusion rate, 4% (n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% (n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% (n = 58) and the rate of occlusion, 4.9% (n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% (n = 4/5).(ABSTRACT TRUNCATED AT 400 WORDS)
PURPOSE: We assessed the outcome of vesicoureteral reflux after augmentation cystoplasty in patients with neurogenic bladder. MATERIALS AND METHODS: Since May 1992, 112 male and 18 female patients with neurogenic bladder have undergone augmentation cystoplasty with a generous detubularized segment of bowel and no effort to correct existing reflux. Patients were treated conservatively at the beginning but the response was unsatisfactory. All patients had various degrees of vesicoureteral reflux (197 refluxing units). Mean age at operation was 21.6 years (range 1.5 to 57). Preoperatively assessment included urinalysis, urine culture, kidney function tests, voiding cystourethrography, urodynamic evaluation, ultrasonography or excretory urography and cystoscopy when indicated. The status of vesicoureteral reflux, renal hydronephrosis and clinical pyelonephritis were studied during an average followup of 44.5 months. RESULTS: Of the 130 patients 111 (85.4%) no longer had reflux, 14 (10.8%) had improvement, 4 (3%) had no change and 1 (0.8%) had worsening reflux. All refluxing units with grades I to III, 105 of 120 with grade IV (87.5%) and 8 of 13 with grade V (61.5%) showed complete cessation of reflux. Renal hydronephrosis improved in 127 renal units (97.7%). In 8 individuals (6.2%) without reflux after cystoplasty episodes of clinical pyelonephritis occurred. CONCLUSIONS: Augmentation cystoplasty without ureteral reimplantation is effective and adequate treatment for high pressure, noncompliant neurogenic bladder when conservative management fails.
A novel technique for an anti-refluxing uretero-ileal reimplantation entailing creation of 2 serous lined extramural tunnels in a detubularized ileal W-bladder is presented. The operation was done on 12 patients in whom an orthotopic bladder substitute was indicated. Mean followup was 18 months. Evidence indicated that this method could provide a nonobstructed unidirectional flow of urine in all of the examined renal units.
In 1987 Firlit et al described their results using Hodgson's technique of the modified extravesical Gregoir-Lich procedure. They coined the term detrusorrhaphy or extravesical ureteral advancement to describe this technique. During the last 4 years we performed this reimplantation on 211 ureters in 132 patients. Of the patients 79 had unilateral and 53 had bilateral procedures. Included were 6 megaureters requiring ureteral tailoring and 9 uncomplicated duplications. All but 1 patient were cured of reflux. No postoperative obstruction was encountered. Our results indicate that this is an excellent procedure to repair vesicoureteral reflux with minimal morbidity and short hospital stay.
In an attempt to create continence in myelomeningocele children we performed urethral lengthening/submucosal reimplantation, a form of bladder neck reconstruction, to create a valve allowing catheterizable access to the bladder. We present the urodynamic findings of 23 patients 4 to 89 months (mean 43.1 months) after bladder neck reconstruction and enterocytoplasty to determine the continence mechanism of this 1-way valve and characteristics of the augmented bladder. Standard cystometrograms with simultaneous pressure recording of the submucosal portion of the neourethra were undertaken with a 10F, triple lumen, urethral pressure profile catheter. Baseline pressures in the submucosal neourethra were higher than in the bladder (mean 25.3 versus 13.4 cm, water, p less than 0.001). Submucosal tunnel and bladder pressures paralleled throughout filling, with mean tunnel pressures remaining greater at the time of first (53.6 versus 45.5 cm. water, p less than 0.01) and peak (62.9 versus 55.8 cm. water, p greater than 0.05) cystoplasty contractions. Bladders augmented with detubularized ileum had fewer significant contractions (greater than 40 cm. water) than other types of cystoplasties (36% versus 92%) and over-all they had first and peak contractions at greater volumes and lesser magnitude. We conclude that continence following urethral lengthening/reimplantation results from an anatomical arrangement allowing transmission of dynamic bladder pressure changes to the submucosal neourethra and that urethral pressure exceeds bladder pressure throughout filling. Additionally, our data suggest that detubularized ileum provides a large capacity, low pressure reservoir suitable for augmentation.
A review of 120 children who underwent ureteral reimplantation by the cross-trigonal or Politano-Leadbetter technique is presented. Over-all success rates (no postoperative reflux or ureteral obstruction) were 96.7% for the Politano-Leadbetter method and 97.8% for the cross-trigonal technique. There were no failures using either method in patients operated upon for primary vesicoureteral reflux.
We reviewed the first 25 urethral lengthening and reimplantation procedures done at our institution in 24 patients. All patients had failed to achieve dryness on medical or surgical therapy for total urinary incontinence. A total of 32 patients had neurogenic incontinence. The patients were followed for 1.5 to 7 years. Late complications included catheterization difficulties, vesicoureteral reflux, febrile urinary tract infection, calculi and peritonitis. Reoperations were required in 19 patients primarily because of our initial failure to recognize the necessity of providing a low pressure, high capacity reservoir. The reoperation rate on the continence mechanism was low. Of 24 patients 20 are continent and require no pads or diapers.
A case of a ureterovesical fistula secondary to ureteral reimplantation is presented. The factors that may have contributed to formation of the fistula are discussed, and the diagnosis and management of this complication are reviewed.
Recurrent urinary tract infection was seen in a 3-year-old girl with a ureterocele at the lower end of the upper segment ureter and reflux into the lower segment ureter of a duplicated kidney on the left side. We combined ipsilateral ureteroureterostomy (end-to-side anastomosis) with reimplantation of the host, single ureter into the bladder distal to the anastomosis to reduce dilatation, correct the reflux and keep the patient free of infection without medication.
Intrarenal reflux was diagnosed in 6 male and 3 female children between 3 weeks and 11 years old, with 13 kidneys affected. One kidney was removed and 12 were managed successfully by antireflux ureteral reimplantation. Followup examination showed satisfactory growth of 10 of the 12 kidneys with intrarenal reflux.
The advantages of a distal tunnel ureteral reimplantation have been elaborated upon previously. This method offers simplicity of transvesical explosure, rapidity of execution, excellent visibility of the terminal ureteral segments, minimal dissection and trauma in the paravesical space, the opportunity to advance the ureteral orifices to a physiologic position on the trigone and minimal risk of angulation, kinking or obstruction of the terminal ureter. It is now recognized that this method, with the modifications discussed herein, has wide applicability in the management of vesicoureteral reflux of all varieties and etiologies.
OBJECTIVES: To evaluate the patients in our practice to determine whether postoperative cystography was useful in monitoring the outcome after ureteroneocystostomy. Surgical repair of vesicoureteral reflux is the treatment of choice after medical therapy failure. Radiographic evaluation by ultrasonography or voiding cystourethrography (VCUG) is commonly used postoperatively to evaluate for urinary tract obstruction or persistent reflux. However, imaging modalities are not without cost, both in monetary terms and in terms of radiation exposure and trauma to the child. METHODS: We reviewed the records of all patients who underwent ureteroneocystostomy without ureteral tapering at our institution between January 1, 1996 and December 31, 1999 for primary vesicoureteral reflux. These records were evaluated with respect to the type of surgical procedure, preoperative and postoperative clinical course, and radiographic studies performed. RESULTS: We performed reimplantation on 267 renal units in 153 patients. The surgical technique was the Cohen cross-trigonal in 120 renal units (45%), Glenn-Anderson ureteral advancement in 92 (35%), and modified Leadbetter-Politano ureteral advancement in 55 (20%). All patients underwent imaging with ultrasonography within 6 weeks of surgery. The follow-up ranged from 4 to 42 months (average 14.2). Between 3 and 8 months postoperatively, 61 patients underwent imaging with VCUG. We identified persistent reflux in six renal units. Four of six had marked improvement in their reflux. All the patients with persistent reflux were asymptomatic, including 2 patients who were no longer receiving antibiotics. Four patients developed febrile urinary tract infections postoperatively. Three of the four underwent imaging with VCUG after treatment; all three had no evidence of reflux. CONCLUSIONS: In our population, the addition of VCUG to the postoperative evaluation did not allow us to identify those patients at risk of febrile urinary tract infections. Patients in whom persistent reflux was identified were all asymptomatic. We continue to monitor patients with ultrasonography, but believe that VCUG often provides little benefit to these children.