Background: There is a growing interest in reporting satisfaction levels of transgender women undergoing vaginoplasty surgery. The lack of information regarding satisfaction during the initial experience of the vaginoplasty technique, and the moderate morbidity related to the surgery, could discourage the immersion of new groups in initiating a program of this kind. Therefore, we aim to report patients' level of satisfaction during our initial experience in the penile inversion vaginoplasty technique.Methods: Retrospective study of patients who underwent penile inversion vaginoplasty in our center between September 2019 and August 2021. Surgery technique, demographic data, preoperative clinical variables, and short and long-term follow-up are described. Six months after surgery, a survey elaborated by the research team was conducted by phone. The score goes from 1 to 5, and it evaluates satisfaction on esthetics, functional, psychosocial, and global aspects.Results: Twenty patients underwent penile inversion vaginoplasty in our center during the described period. The average age was 35.6 years old, the mean body mass index (BMI) was 24.7 kg/m 2 , and they presented low comorbidity. Half of the patients presented at least one complication, most of which were minor. One patient was urgently reoperated due to bleeding, and three patients were reoperated on a scheduled basis from minor surgeries. 90% of the patients answered the questionnaire. The most common answers to all four areas covered (esthetics, functional, psychosocial, and global) were satisfied or very satisfied, resulting in a mean over four points in each one of the sections. Lastly, 94.4% of the patients reported being satisfied with their choice of having undergone surgery.Conclusions: Our initial experience in penile inversion vaginoplasty reveals good satisfaction results at short follow up.
computed tomography scan revealed compression of the left renal vein under the superior mesenteric artery. She underwent a venogram with intravenous ultrasound, which demonstrated >90% narrowing of the left renal vein under the SMA, diagnostic for Nutcracker Syndrome.RESULTS: After positioning in Trendelenburg position and obtaining pneumoperitoneum, ports were placed similar to a robot assisted retroperitoneal lymphadenectomy procedure. The retroperitoneum was exposed by incising the posterior peritoneum and tacking this to the anterior abdominal wall. The inferior vena cava (IVC) was identified and skeletonized, with emphasis on identification and dissection of the left renal vein. Vascular control was obtained using modified Rummell tourniquets. During our dissection, we identified a dilated and prominent left gonadal vein. We anastomosed the distal aspect of the left gonadal vein to the IVC, to provide constant venous outflow from the left kidney during transposition of the left renal vein. With the left kidney draining through both the left renal and gonadal vein, the left renal vein was stapled flush with the IVC. We then performed left renal vein transposition by anastomosing the left renal vein to the IVC below the left of the previous insertion with Gore-Tex suture. Vascular clamps were removed to assess the integrity of the anastomoses, and hemostasis was excellent. Total estimated blood loss was 50mL, and total operative time was 3 hours and 19 minutes. Postoperative creatinine improved to 0.57 mg/dL from 0.75 mg/dL preoperatively. The patient was discharged on postoperative day one. At 6 weeks follow up, her flank/abdominal pain had completely resolved.CONCLUSIONS: Robot assisted renal vein transposition is a feasible and safe alternative to open transposition for Nutcracker Syndrome. Transposition of the left renal vein without venous outflow obstruction is possible when utilizing the native gonadal vein as a conduit to the IVC. Using this approach, adequate venous outflow can avoid nephron injury.
considered statistically significant. The statistical package SPSS V 25 and GraphPad Prism were used.RESULTS: Arterial anastomosis time was below the alarm/alert line in 93.3%/88.9% of RAKTs, while venous anastomosis time was below the alarm/alert line in 88.9%/73.9%. The non-anastomotic rewarming time (RWT) exceeded þ3SD in 24.7% of procedures and þ2SD in 37.1%. In only 46% cases was the RWT below the alert line. The ureterocystoneostomy time was below þ2 and þ3SD in 87.9% and 90.2% of cases, respectively. CUSUM showed that the learning curve for arterial anastomosis required up to 35 (mean[16) cases. Complications and delayed graft function rates decreased significantly and reached a plateau after the first 20 cases. A similar conclusion was reached for venous anastomosis, which may need more than 40 procedures (mean [24). The plateau in the ureterocystoneostomy curve was reached within 30 RAKTs in 4/5 centers (mean[17). The plateau for RWT was reached within 23 procedures at center 1, 44 at center 2, and 38 at center 3 (mean 35 cases); centers 4 and 5 did not reach the plateau. Interestingly, the curves for non-anastomotic time during RWT resemble those for RWT. On the linear regression model, all the anastomotic times were comparable. The slopes in respect of non-anastomotic time during RWT were slightly different (p[0.0006), as was also true for RWT itself (p[0.007).CONCLUSIONS: A minimum of 35 cases is necessary to reach reproducibility in terms of anastomosis time, rewarming time and functional results.
INTRODUCTION AND OBJECTIVE: Robot-assisted kidney transplantation (RAKT) has been shown promising results in grafts coming from living donation. However, this technique has two main limitations. First, grafts coming from cadaveric donors, usually reserved to patients with advanced systemic disease who often present iliac artery plaques, are excluded from RAKT because of the lack of intraoperative haptic feedback. For this reason, we introduced 3D imaging reconstruction in RAKT through the augmented reality (AR) in order to intraoperatively guide the surgeon, showing where to put the clamps and perform arteriotomy in the recipient iliac artery. Second, the regional hypothermia during rewarming time is guaranteed by intermittent ice slush insertion in the abdominal cavity, which may be suboptimal and increase the risk of ileus. To overcome this limit, we developed and tested a cold ischemia device (CID) with the aim to maintain a low and constant graft temperature while avoiding ice slush introduction.METHODS: These two projects were conducted according to IDEAL model for surgical innovation. In the first project, iliac artery anatomy together with plaques was represented in a 3D printed model. Firstly, this model was used in open kidney transplantation (OKT) setting in order to test the accuracy of the 3D reconstruction, comparing it with intraoperative tactile feedback. Subsequently, we employed this technology in the AR setting, in two cases without plaques. Finally, we tested AR in a patient with plaques. In the second project, the cooling device was developed and tested in an ex-vivo setting to assess its cooling performances. In phase 2a, the device was used in an in-vivo porcine model to evaluate the feasibility to perform both a complete OKT and RAKT. In phase 2b, CID was employed in 4 patients undergoing OKT or RAKT from living donors. Graft temperature was monitored using a thermal probe.RESULTS: The 3D-AR enabled to clamp the artery in the correct position and to find the right place to perform arteriotomy. Phase 2 demonstrated that both OKT and RAKT can be performed with the support of CID in a clinical setting, without any modification in our standard technique or perceived lengthening of the operative time. Graft temperature never exceeded 20 C. No complications related to the use of both these devices were recorded.CONCLUSIONS: These new tools were designed to overcome RAKT's main limitations, optimizing the graft cooling system and including patients with atheromatic vascular disease, paving the way to expand the indications of RAKT.
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