Medical Instructor, University of Chicago Pritzker School of Medicine
The rise of microsurgery as a surgical discipline followed three advances: (1) refinements in optical magnification blood pressure medication cost purchase furosemide online from canada, (2) the development of more precise microsuture and microneedles arrhythmia nos discount 100 mg furosemide, and (3) the ability to manufacture smaller and more refined surgical instruments prehypertension readings purchase furosemide 40mg on-line. In urology blood pressure medication orange juice 40mg furosemide free shipping, microsurgery was first applied to renal transplantation and vasectomy reversal. The most commonly performed microsurgical procedure in urology is vasectomy reversal. The most common reason for vasectomy reversal is remarriage and the desire for more children. Occasionally, an unfortunate individual will have chronic pain after vasectomy or have lost a child and desire another. Infection, congenital deformities, trauma, and previous surgery are less frequent indications for vasovasostomy or epididymovasostomy (see Plate 5-4). Although there are several methods for performing vasovasostomy, including a modified single-layer anastomosis and a strict, two-layer anastomosis, neither is proven superior to the other. Importantly, optical magnification with an operating microscope improves outcomes as smaller sutures can be used, reducing cicatrix formation and failure rates. In the best hands, 95% to 99% of patients have a return of sperm after vasovasostomy. At the time of vasectomy reversal, the vas deferens is transected below the vasectomy site. If the fluid egressing from the vas deferens contains no sperm, a second acquired obstruction may exist in the delicate tubules of the epididymis. As more time passes after vasectomy, the greater will be the "back-pressure" behind the blocked vas deferens, causing a "blowout" at some point in the 18-foot-long microscopic epididymal tubule. In this case, the abdominal vas deferens must be connected to the epididymis proximal to the blowout to bypass both sites of obstruction and to reestablish reproductive tract continuity in a procedure termed epididymovasostomy. For epididymovasostomy, the epididymis is exposed by opening the tunica vaginalis that surrounds the testis. The epididymis is inspected and an individual tubule selected that appears dilated and is proximal to the obstruction. Two different approaches to epididymovasostomy are now popular: the mucosa-to-mucosa endto-side method and the invagination approach. With the traditional mucosal approach, the opened epididymal tubule is connected to the cut end of the vas deferens, with four to six small microsutures placed radially around the circumference of each. This "inner" layer is buttressed with another, "outer" layer of radially placed microsutures to strengthen the delicate connection. With the invagination method, one, two, or three "vest" microsutures are placed near but not into the opening Microsurgical two-layer vasovasostomy Two-layer Modified one-layer Inner layer closure Microsurgical vasovasostomy approaches Outer layer closure Mucosa to mucosa epididymovasostomy Vasal fluid sampling A2 B1 A2 B2 C1 A1 C2 C1 A1 C2 B1 B2 "Vest" suture placement Invagination epididymovasostomy Vasostomy closure after vasogram of the epididymal tubule to allow the epididymal tubule to be drawn into, or "invaginated" into, the lumen of the vas deferens, theoretically creating an improved watertight seal. After epididymovasostomy, approximately 60% to 80% of men will have sperm in the ejaculate. In cases of idiopathic epididymal obstruction, a similar approach as that taken for vasectomy reversal is employed, except for an important difference. Because there is no iatrogenic blockage of the vas deferens with idiopathic obstruction, the fluid within the vas deferens is sampled from, and the vas deferens inspected by, vasography instead. After puncturing or hemitransecting the straight segment of the scrotal vas deferens, diluted dye or contrast medium is injected into the vas deferens toward the bladder from the scrotum. In plain-film radiographs, contrast delineates the proximal vas deferens, seminal vesicle, and ejaculatory ducts and the site of obstruction can be determined. In addition, the finding of no sperm in the vasal fluid from the testis side of the vas deferens implies that there is an obstruction present in the epididymis. With this information, the site of obstruction can be accurately determined and the system microsurgically reconstructed with either vasovasostomy or epididymovasostomy. This provides definitive evidence of either obstructive or nonobstructive azoospermia. The technique involves a small, open incision in the scrotal wall and testis tunica albuginea under local anesthesia. A small wedge of testis tissue is removed, examined histologically, and seminiferous tubule architecture and cellular composition are assessed (for patterns, see Plate 3-21). Alternatively, percutaneous sampling of testis tissue with a biopsy gun can be used, similar to that employed for prostate biopsy. Although several excellent descriptions of testis seminiferous epithelium histology have been reported, no individual classification has been uniformly adopted as a standard approach. A testis biopsy is not usually indicated for cases of oligospermia (low sperm count), as partial reproductive tract obstruction is very rare. In addition, although a single, unilateral testis will define excurrent ductal obstruction, the finding of two asymmetric testes may warrant bilateral testis biopsies to best define the pathology. With normal sperm production, formal investigation of the reproductive tract for obstruction is warranted, beginning with a vasogram (see Plate 5-5). The testis biopsy may also indicate the premalignant condition, intratubular germ cell neoplasia, that tends to occur globally within the affected testis. This condition exists in 5% of men with a contralateral germ cell testis tumor and is more prevalent in infertile than fertile men. A single testis biopsy will detect the presence of sperm in 30% of men with nonobstructive azoospermia. Other surgical and nonsurgical approaches have sought to improve the "yield" of sperm in cases of testis failure. It is now clear that men with nonobstructive azoospermia can have "patchy" or "focal" areas of sperm production in a testis otherwise devoid of mature sperm. With the multibiopsy method, four to six individual testis biopsies are taken from different areas of the testis to increase the odds of finding sperm in any particular tissue sample. Similar to other "open" or percutaneous testis biopsy methods, fine-needle aspiration mapping is performed under local anesthesia. Unlike these techniques, however, smaller tissue samples are obtained that are then examined cytologically instead of histologically.
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The dissection extends inferiorly between the duodenum and the cyst and medially and laterally hypertension bp proven furosemide 100mg, keeping close to the cyst wall arrhythmia signs and symptoms cheap 100 mg furosemide with mastercard, using precise bipolar cautery to achieve safe and accurate hemostasis hypertension questions and answers discount furosemide 40mg with amex. The distal common bile duct is dissected to just within the head of the pancreas and transected pulse pressure hemorrhage generic furosemide 40 mg without a prescription. The operative cholangiogram gives a useful guide to the distal level of bile duct transection. Protein plugs or calculi within a common channel should be removed using a combination of saline irrigation, balloon catheters and, when possible, intraoperative endoscopy using a pediatric cystoscope. The distal bile duct stump is then over-sewn with an absorbable monofilament suture. The common hepatic duct is divided at the level of the bifurcation, where it should appear healthy and well vascularized. Any dilated proximal intrahepatic ducts are cleared of debris by catheter irrigation with normal saline and, in larger ducts, with the aid of choledochoscopy. Anastomosis to a narrow common hepatic duct should be avoided because of the long-term risk of stricture. At this point, there is a suitable vascular arcade to create a Roux loop that will reach the hilum of the liver without tension. The stapled end of the Roux loop is over-sewn with an absorbable suture and passed through a window in the transverse mesocolon to the right of the middle colic vessels. The anastomosis is constructed a few millimeters from the end of the Roux to avoid the development of a blind pouch with future growth of the bowel. Mesenteric defects in the transverse mesocolon and small bowel mesentery are closed with sutures. A liver biopsy is performed at the end of the operation to document hepatic histology. The operative field is washed with warm saline and, in straightforward cases, the abdomen is closed without drainage. Proponents of the latter argue that it is more physiological, associated with less risk of adhesion obstruction, and minimizes the loss of absorptive mucosa, but duodenogastric reflux of bile can be a problem and there are concerns about a long-term risk of anastomotic malignancy. The appendix should not be used as a conduit (hepaticoappendico-duodenostomy) because of a high incidence of subsequent biliary obstruction. Hilar ductal strictures may necessitate some form of ductoplasty or extended anastomosis. The addition of a transduodenal sphincteroplasty should be considered if the common channel is very dilated and contains debris. Intramural resection of the posterior wall of the cyst (excising only the mucosa and inner wall) can help to avoid damage to the portal vein. The cyst lining is completely removed, but a portion of the outer wall remains posteriorly. Smaller choledochoceles can be treated by sphincteroplasty or endoscopic sphincterotomy if there is no pancreatobiliary malunion. Type V cysts: if the cysts are multiple and confined to one side of the liver, hepatic lobectomy may be curative. If multiple cysts are distributed throughout the liver, recurrent cholangitis and stone formation are common. Antibiotics and drainage procedures are helpful, but liver transplantation should be considered in progressive cases. Three additional 5- or 3-mm trocars are placed for instruments: one at the right flank, one at the left flank, and the final one in the left hypochondrium. The jejunum is exteriorized, and the jejunojejunostomy is carried out extracorporeally. A second traction suture is placed at the distal cystic duct to elevate the liver and splay out the liver hilum. Separation of the cyst from the hepatic artery and portal vein is carried out 16b meticulously (16a) until a dissector can be passed through the space between the posterior wall of the cyst and portal vein proceeding from left to right (16b). Protein plugs or calculi within the cyst and common channel are washed out and removed. Irrigation with normal saline via this catheter is performed to eliminate any protein plug until the catheter can be passed down to the duodenum. The distal choledochal cyst is clipped and divided at the level of the orifice of the common channel. The choledochal cyst is initially divided at the level of the cystic duct, and after identifying the orifice of the right and left hepatic ducts, the definitive division is performed. The common hepatic duct is irrigated with normal saline to wash out biliary debris and calculi. Irrigation with normal saline through a small catheter inserted into the right and then into the left hepatic duct is performed to wash out the protein plugs or calculi until the fluid from those ducts is clear. Irrigation with normal saline in the remnant is carried out to wash out debris and calculi.
In the Tanner staging of puberty heart attack high the honeymoon is over discount 40mg furosemide fast delivery, this is stage 2 of breast development (stage 1 is a flat pulse pressure of 80 purchase 100 mg furosemide free shipping, prepubertal breast) prehypertension symptoms purchase 100mg furosemide with visa. Within 6 to 12 months heart attack japanese discount 100mg furosemide fast delivery, the swelling is bilateral, softer, and extends beyond the areolae (stage 3). In another year (stage 4), the breasts are approaching mature size and shape, with areolae and papillae forming a secondary mound. Pubic hair is often the second change of In males, testicular enlargement is the first physical sign of puberty and is termed gonadarche. Testes in prepubertal boys change little in size from 1 year of age until puberty, averaging about 2 to 3 mL in volume. Testicular size increases throughout puberty, reaching maximal adult size 6 years later. Although 18 to 20 mL is the average adult testis size, there is also wide ethnic variation. The testis Leydig cells produce testosterone that induces most of the changes of sexual maturation and maintains libido. Most of the increasing bulk of testicular tissue is due to growth of seminiferous tubules, including Sertoli cells. The sequence of sperm production and the onset of fertility in males is not as well documented, largely because of the variable timing and onset of ejaculation. Sperm can be detected in the morning urine of most boys after the first year of puberty and potential fertility can reached as early as 13 years of age, but full fertility is not achieved until 14 to 16 years of age. As in females, the first appearance of pubic hair is termed pubarche and hairs are usually first visible at the base of the penis. The Tanner stages of hair growth are similarly classified in males and females, as described earlier. Following the appearance of pubic hair, other body areas that respond to androgens develop heavier hair (androgenic hair) in the following sequence: axillary hair, perianal hair, upper lip hair, sideburn hair, periareolar hair, and facial beard. Under the influence of androgens, the voice box, or larynx, grows in both genders. Far more prominent in males, this growth causes the male voice to deepen about one octave, as the vocal cords lengthen and thicken. Voice change can be accompanied by unsteadiness of vocalization in the early stages. Most of the voice change occurs in stages 3 to 4 of male puberty, around the time of peak growth. Full adult voice pitch is attained at an average age of 15 years, usually preceding the development of facial hair by months to years. By the end of puberty, adult men have heavier bones and nearly twice as much skeletal muscle as females. The average adult male has about 150% of the lean body mass of an average female and about 50% of the body fat. The peak of the "strength spurt" is observed about 1 year after the peak growth rate. As with females, rising levels of androgens change the fatty acid composition of perspiration, resulting in adult body odor and acne. As discussed in Plate 1-5, androgens are converted to estrogens in the male by aromatase and because of this, male adolescence is frequently (80%) accompanied by gynecomastia. Most patients experience a delay in puberty, although those with less severe defects may present with only infertility. Other findings include anosmia and midline abnormalities such as cleft palate and small testes. As a consequence, there is failure of testicular stimulation by the anterior pituitary and hypothalamus and thus testis failure in addition to anosmia. Primary testis failure, causing an inadequate testosterone surge at puberty and exemplified by Klinefelter syndrome, may also produce a delay in the onset or sequence of pubertal events (Plate 1-7). This syndrome may present with delayed puberty, increased height, decreased intelligence, varicosities, obesity, diabetes, leukemia, increased likelihood of extragonadal germ cell tumors, and breast cancer (20-fold higher than normal males). In idiopathic form (50% of cases), puberty proceeds in a normal pattern but begins earlier and is compressed into a shorter time frame. Although affected males are tall for their age during early puberty, the premature closure of the epiphyses results in a markedly short stature in adulthood. Central causes of precocious puberty include brain tumors near the third ventricle, including astrocytoma, meningioma, or pinealoma, and are usually accompanied by diabetes insipidus and visual field defects. It can also be associated with congenital malformations such as hematomas of the brain. The classic form is the more severe of the two and affects very young children and newborns. The nonclassic form is milder and usually develops in late childhood or early adulthood. Signs and symptoms of the classic condition in older children and adults include rapid growth during childhood, very early puberty with the development of pubic hair and deepening of the voice, shorter than average final height, and infertility. In addition, large quantities of cortisol precursors are made that form the substrates for androgens. Excessive androgens contribute to the virilization and also downregulate pituitary gonadotropin secretion, so that the testes remain small and infantile despite other pubertal changes. The clinical signs of a virilizing adrenal adenoma or cortical carcinoma are similar to those induced by any other cause (Plate 1-8). These conditions can be differentiated from other causes by the lack of suppression of 17-ketosteroid secretion with exogenous glucocorticoids.
Alternatively blood pressure chart with age and gender buy cheap furosemide 100mg, patients may undergo complex repair of their severe hypospadias and be reared as a male prehypertension 2016 cheap furosemide uk. In either case pulse pressure test cheap generic furosemide canada, long-term follow up will be needed pulse pressure low furosemide 40 mg for sale, as gender reassignment has occurred regardless of initial gender designation. If the patient is already committed to the male role, then hypospadias repair will be required. The gonads must be carefully observed for tumor development, which may occur as early as the newborn period. However, there is a lack of sufficient longterm results regarding sexual function and acceptance of genital appearance in most patients, because most of the published studies have analyzed patients who have been reconstructed by operative techniques, which have been more recently modified. Preoperative evaluation 947 preoperatIve evaluatIon Imaging evaluation 1a,b, 2 A retrograde genitography is performed by occluding the opening of the urogenital sinus with the inflated balloon of a size 8 Fr Foley catheter placed outside the meatus and secured in place with tape; lateral and oblique images are required. In approximately 80 percent of the cases, the level of confluence of the urogenital sinus in relation to the bladderneck and external sphincter can be identified, thus facilitating the planning of the surgical procedure C P B C P B R V R V 1a low confluence 1b high confluence 2 low confluence 948 Surgical treatment of disorders of sexual development 3, 4 Ultrasonography gives important information about the urinary tract and the uterus, vagina, and gonads can be visualized. If needed, ondansetron may be indicated to prevent nausea, or Golytely can be administered through a small nasogastric tube. The use of Golytely should be discontinued at least 24 hours before surgery to avoid leakage during the procedure. Magnesium citrate, which shrinks the bowel, is given on the last day to prevent leakage. Oral administration of neomycin plus erythromycin can be prescribed to reduce bacterial concentration. Patients on dexamethasone are asked to omit this medication, but children on prednisone take the usual morning dose on the day of surgery. The key steps of a feminizing genitoplasty are clitoroplasty, labioplasty, and vaginoplasty. Surgical procedures must preserve clitoral sensation and result in normal looking external genitalia, with a well-lubricated vagina, which will allow satisfactory and painless sexual intercourse. Due to some concerns regarding the benefits of clitoroplasty, it should be undertaken only after extensive discussions with the Reconstruction for female gender assignment 949 surgical reconstruction Planning and timing the surgical reconstruction the magnitude and timing of surgical reconstruction is the subject of significant controversy. Some groups advocate delaying sex assignment to an age in which each patient can make his or her own decisions; however, as mentioned earlier, most of these studies have been based on analysis of the outcomes of older surgical procedures. The authors believe that newer techniques result in an improved cosmetic appearance, a reduced complication rate, and are more likely to preserve sensation. All available treatment alternatives are discussed with the parents, and recommend that the different steps of the surgical reconstruction should be incorporated into a single surgical procedure, and be performed at an early age in order to take advantage of all available tissues, with the objective of achieving the best possible functional and cosmetic results. Patients with a low confluence urogenital sinus can be operated once their metabolic management is well controlled; in most cases, the authors undertake an elective reconstruction at between three and six months of age, but repair can be done in the newborn period if the social situation so warrants. Adequate and controlled hormonal treatment is needed to prevent clitoral hypertrophy after correction. Planning of the surgical reconstruction should incorporate the three components of a feminizing genitoplasty, in which the prepuce is used to create labia minora, if needed the clitoris is reduced, and the labiosacrotal swellings are used to fashion female-appearing labia majora and to enhance the vaginoplasty. To improve surgical exposure, the authors use a hyperextended lithotomy position with the buttocks lying over and slightly beyond several folded towels. For surgical planning, one must precisely find the location of the confluence point between the vagina and urethra in relation with the bladderneck and the external sphincter. Those anomalies with the confluence point at or above the veru montanum/external sphincter are considered high, and those below are considered low. The prostatic utricle is characteristically found in the center of a flattened veru montanum, but has no surrounding prostatic tissue. In those patients with a mid-level and high confluence, a Fogarty catheter with a stopcock valve is passed into the vagina and the balloon is inflated; a small Foley catheter is also placed in the bladder, and both are labeled and tied together (see also illustration 1a,b). Urethra Verumontanum external sphincter Proximal vagina Vaginal orifice external sphincter 5a 5b 950 Surgical treatment of disorders of sexual development 6 Clitoral resection and recession are of historical interest and no longer recommended. The goal of current techniques is to preserve sensation for future orgasms, provide an acceptable cosmesis, and avoid painful erections. A subtunical excision of the erectile tissue has been used extensively and led to newer nerve-sparing techniques. Circumferential branches from the dorsal neurovascular bundle encircle the clitoral shaft toward the ventrum, thus making a ventral approach to the corpora most likely to avoid nerve injury. In cases with severe masculinization, the clitoris is too large resembling a penis; in such cases, the authors discuss the anatomical characteristics with the parents and advise a clitoroplasty. Two vertical incisions are outlined with a marking pen on each side of the urethral plate, and the meatus is circumscribed as for hypospadias surgery, taking care to leave a redundant segment of dorsal inner foreskin to fashion a hooded prepuce, thus preserving an important source of sensation. The clitoris is degloved; the ventral strip of the urethral plate should initially be kept intact. Next, clitoral reduction is carried out; the authors do not use a tourniquet as it has been observed that bleeding from the erectile tissues is not significant, particularly in infants, although it can be considerable in the older child. Longitudinal ventral incisions are made; the erectile tissue is dissected within the bodies. The body of the glans is sutured to the corporal body stumps with absorbable sutures. The redundant dorsal tunica albuginea and neurovascular bundle are placed in a subcutaneous pocket above the pubic bone, taking care not to impair the neurovascular elements.
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