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In the radial forearm phalloplasty multiple nerves are harvested to provide phallic sensation, resulting in iatrogenic nerve injuries. Despite this, nerve morbidity following this procedure has been minimally assessed. The purpose of this study was to assess donor site nerve morbidity following radial forearm phalloplasty.Patients who underwent gender-affirming phalloplasty at our institution between 2016-2020 using the radial forearm were included. Pain characteristics were assessed with a modified Mackinnon Pain questionnaire consisting of 33 items, including visual analog scales (VAS) for reporting of pain and impact on aspects of quality of life (QoL), as well as 20 descriptive pain adjectives and a 21-item questionnaire to capture overall pain experience.A total of 37 patients were included. 31 had minimal-mild pain (VAS scores 0-3), and 6 patients had moderate-severe pain (VAS scores 4-10). The mild pain group reported a mean 2.74 (0-7) pain descriptors and reported minimal impact on QoL metrics. The moderate-severe pain group reported mean 6.33 (2-15) pain descriptors and reported significant impacts on QoL metrics. Significant differences were observed with decreased QoL (p = 0.018), increased sadness (p = 0.009), increased frustration (p = 0.030), increased anger (p = 0.0496), and decreased hopefulness (p = 0.0496) in the moderate-severe pain group along with interference of pain with sleep (p = 0.002).In a cross-sectional analysis of 37 patients who underwent gender-affirming radial forearm phalloplasty, the majority (31) experienced a minimal degree of donor site nerve pain. Six patients suffered from more significant nerve pain that was associated with a decreased QoL. Treatment and prevention of this nerve pain represent important areas for future exploration.

Background Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. Methods This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Results Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. Conclusion PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

SUMMARY The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

Background Phalloplasty often requires free tissue transfer. There is ample literature describing flap-related outcomes, but the microsurgical technique used, including choice of recipient vessels, has been an overlooked yet important topic. In this study, the authors review the outcomes of their experience with the deep inferior epigastric artery and locoregional veins and outline technical modifications that occurred during the study period. Methods A retrospective chart analysis of patients who underwent microsurgical phalloplasty between September of 2016 and July of 2019 was performed. Variables included flap design, donor site, and recipient vessels. The outcome measures were return to the operating room for flap compromise and partial or complete flap loss. Results Forty-two phalloplasties using the deep inferior epigastric artery were identified. There were six take-backs for flap compromise, and four patients required venous revision, one of whom lost his urethral flap on postoperative day 9. There was a decrease in take-back rate from 30 percent in the first 20 patients to 0 percent in the second 22 patients in the study period. A total of 11.9 percent of patients had partial flap loss. This decreased from 15 percent to 9 percent in the two groups. Conclusion After an initial learning curve, the combination of deep inferior epigastric artery, deep inferior epigastric vein, and great saphenous vein combined with specific technical modifications such as targeted coagulation of the vasa nervorum of the clitoral nerve has proven to be a reliable technique. Clinical question/level of evidence Therapeutic, IV.

Objectives There are multiple approaches to vaginectomy for the purpose of masculinizing gender-affirming genital surgery including mucosal fulguration and excision. The outcomes of the approaches are not well described. We aim to describe the surgical outcomes of gender-affirming vaginectomy and colpocleisis by complete mucosal excision. Methods We performed a case series study of 40 transmasculine patients who underwent gender-affirming vaginectomy and colpocleisis. Vaginectomy was performed by complete excision of the vaginal mucosa via a transperineal approach. We recorded perioperative outcomes and operative time. We performed a multivariate analysis to assess patient factors on operative outcomes. Results Forty vaginectomies were performed between September 2016 and April 2019, 27 (67.5%) in phalloplasty patients and 13 (32.5%) in metoidioplasty patients. Perioperative complications included 2 blood transfusions, 1 pelvic hematoma, and 1 Clostridium cifficile colitis. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased significantly with later surgery year. Conclusions This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.

OBJECTIVE. Masculinizing genital surgeries for transgender individuals are currently performed at only a select few centers; however, radiologists in any geographic region may be confronted with imaging studies of transgender patients. The imaging findings of internal and external genital anatomy of a transgender patient may differ substantially from the imaging findings of a cisgender patient. This article provides the surgical and anatomic basis to allow appropriate interpretation of preoperative and postoperative imaging findings. We also expand on the most common complications and associated imaging findings. CONCLUSION. As these procedures become more commonplace, radiologists will have a growing role in the care of transgender patients and will be faced with new anatomic variants and differential diagnoses. Familiarity with these anatomic variations and postoperative complications is crucial for the radiologist to provide an accurate and useful report.

Background Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. Methods This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. Results A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. Conclusions We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

SUMMARY Genital masculinizing gender-affirming surgery is a growing field. Because of a spectrum of gender identity, gender expression, sexual expression, patient desires, and patient tolerance for complications, options for surgery vary accordingly. Shaft-only phalloplasty avoids urethral lengthening, but may still be accompanied by hysterectomy, vaginectomy, scrotoplasty, clitoroplasty (burying of the clitoris), glansplasty, and placement of erectile devices and testicular implants. Patients who desire retention of vaginal canal patency are candidates for vaginal preservation vulvoscrotoplasty; however, there is a paucity of literature describing the procedure and its outcomes. In this article, the authors review the technique used by the senior author at Oregon Health and Science University and report surgical outcomes for four patients. Future studies regarding patient-recorded outcome measures, aesthetics, sexual function, urologic function, patient satisfaction, and conversion to other options will help surgeons better understand patients pursuing gender-affirming surgery through shaft-only phalloplasty.

Gender dysphoria, or the distress caused by the incongruence between a person's assigned and experienced gender, can lead to significant psychosocial sequelae and increased risk of suicide (>40% of this population) and assault (>60% of this population). With an estimated 25 million transgender individuals worldwide and increased access to care for the transgender population, trauma surgeons are more likely to care for patients who completed or are in the process of medical gender transition. As transgender health is rarely taught in medical education, knowledge of the unique health care needs and possible alterations in anatomy is critical to appropriately and optimally treat transgender trauma victims. Considerations of cross-gender hormones and alterations of the craniofacial, laryngeal, chest, and genital systems are offered in this review. Further research on the optimal treatment mechanisms for transgender patients is needed.

Background Gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. Aim Our objective is to describe the factors influencing patient choice or surgeon recommendation of vulvoplasty and to assess the patient’s satisfaction with this choice. Methods Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. Outcomes We report demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. Results In total, 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty. 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index than those seeking vaginoplasty. The majority (63%) of the patients seeking vulvoplasty chose this surgery despite no contra-indications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision for vulvoplasty. Clinical Translation Vulvoplasty creates the external appearance of female genitalia without creation of a neovaginal canal; it is associated with high satisfaction and low decision regret. Conclusions This is the first study of factors impacting a patient’s choice of or a surgeon’s recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also is the first reported series of patients undergoing vulvoplasty only. Limitations of this study include its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how we offer vulvoplasty. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

The authors present their grading scale and the outcomes of the largest cohort of top surgery published to date. Application of this grading system can help determine which patients will benefit from a subcutaneous mastectomy with free nipple graft versus a circumareolar technique, with the primary endpoint being need for aesthetic revisions.The authors reviewed their database of transgender males who underwent bilateral mastectomy between 2006 and 2015. Data collected included age, body mass index, American Society of Anesthesiologists class, smoking, diabetes, testosterone use, months of social transition, technique used, postoperative complications, and need for revision. Two techniques were used, circumareolar incision and free nipple graft technique.Between 2006 and 2015, 1686 consecutive mastectomies were performed on 843 patients. Of those, 548 patients were excluded because of inadequate follow-up. Of the 295 included, 109 were treated using a circumareolar incision and 186 were treated using a free nipple graft technique. There was no statistically significant difference in complications between the two groups; however, there was a statistically significant difference in the rate of aesthetic revisions in the grade 2B circumareolar incision group (34 percent versus 8.8 percent).The authors' outcomes are comparable to the literature, and demonstrate that these procedures can safely be performed in an outpatient setting. The authors' grading scale classifies patients and helps the surgeon select a surgical technique. The authors show a statistical difference in rates of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique.Therapeutic, III.

The treatment of gender dysphoria related to genitourinary anatomy can be effectively treated with phalloplasty. A phalloplasty may include some or all of the following: penile shaft, glans, shaft urethra, perineal urethra, scrotoplasty, vaginectomy, testicular implants, and erectile devices. The literature does not currently support a gold standard for how best to stage these procedures. This article reviews current techniques for phalloplasty staging and proposes that a staged urethral reconstruction is a reliable technique that allows for potential complications to be managed individually, while minimizing the severity of complications and their impact on the outcome of the final reconstruction.

The population of transgender patients seeking gender confirmation surgery for gender dysphoria is increasing in the United States. Facial gender confirmation surgery (FGCS) is one of the treatment modalities patients require and is often a combination of soft tissue and cranio-maxilla-facial procedures. Despite evidence of the efficacy of FGCS, there remains some extant controversies to address, such as reimbursement for these procedures, categorization of aesthetic versus functional surgery, and evaluation of outcomes. This review provides a discussion of these topics, as well as the historical and psychosocial issues specific to transgender patients that surgeons should know when providing FGCS. We provide practice pearls for providing affirming transgender healthcare, illustrative patient clinical vignettes, and a discussion of the Standards of Care of the World Professional Association for Transgender Health to help guide surgeons who are interested in providing FGCS to transgender patients.

Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

BACKGROUND:Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES:We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS:This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS:A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS:Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population. LEVEL OF EVIDENCE: 4

This article focuses on flap-related complications after creation of a neophallus for transgender individuals. It outlines the most frequently used flaps for this procedure and how flap-related complications can affect the overall outcome of the phalloplasty. With surgeons staging the procedure in different stages, it is important to understand the different strategies and the implication a flap-related complication can have on the end result and how it may be prevented.

To analyze, using 3-dimensional photogrammetric data, midfacial soft tissue and volumetric changes in the cleft maxilla after 1- or 2-piece Le Fort I (LF1) advancement.This was a retrospective study of patients with cleft and maxillary hypoplasia who underwent LF1 advancement. The primary predictor variable was the type of advancement (1 piece vs 2 pieces). Outcome measurements were changes in soft tissue linear measurements (subnasale [Sn], labium superius [LS], and stomion [SO]) and midfacial volume after maxillary advancement.Eleven patients (7 male, 4 female) underwent LF1 advancements (4 underwent 2-piece advancement). The mean maxillary advancement was 6.2 ± 1.7 mm. Soft tissue changes at the Sn, LS, and SO were 5.2 ± 2.0, 5.8 ± 2.5, and 5.2 ± 1.8 mm, respectively. The average volume change was 12.2 ± 5.7 cm(3). The mean ratios of soft tissue change to the amount of maxillary advancement (millimeters per millimeter) at the Sn, LS, and SO were 0.89 ± 0.49, 0.97 ± 0.44, and 0.89 ± 0.34, respectively. Volume increased by 2.1 ± 1.3 cm(3)/mm. Patients undergoing 1-piece advancement had greater mean advancement and greater soft tissue changes at the LS and SO (P.03). After controlling for the amount of advancement, 1-piece LF1 osteotomy showed significantly greater improvements at the LS and SO (P .04).Midface advancement at the LF1 level in patients with cleft consistently expands upper lip soft tissue and midfacial volume. Greater changes at the LS and SO were seen with 1-piece than with 2-piece osteotomy.

Background In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to a matched control population. Methods We performed a retrospective analysis of our database between 1997 and 2012. We divided the cases into early (

Background Gender dysphoria is estimated to occur in up to 0.9 percent of the U.S. Population With increasing awareness and decreasing stigma surrounding transgender issues, it is predicted that more patients will begin to seek medical and surgical transition. This study aims to determine the current state of transgender-related education in U.S. plastic surgery residency programs and to evaluate trainee perceptions regarding the importance of such training. Methods Plastic surgery trainees from a representative sample of 21 U.S. training programs were asked to complete a cross-sectional eight-question survey between November of 2015 and January of 2016. Respondents were queried regarding demographics, transgender curricular exposure (didactic versus clinical), and perceived importance of training opportunities in transgender patient care. Results A total of 322 residents or fellows responded to the survey (80 percent response rate) from four U.S. Census regions. Sixty-four percent of respondents had education on or direct exposure to transgender patient care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to chest and genital surgery. Overall, the majority of respondents believed that training in gender-confirming surgery is important, and 72 percent endorsed the necessity for gender-confirming surgery fellowship training opportunities. Conclusions A significant number of plastic surgery trainees are exposed to transgender patient care, although exposure type is variable. The majority of trainees endorsed the importance of residency and fellowship training in gender-confirming surgery. To better serve the transgender population, formal fellowship training in gender-confirming surgery should be offered.

A 55-year-old man was treated for Fournier gangrene in 2004 with radical debridement and bilateral testicular transposition to the medial thighs. Eight years later, bilateral hydroceles formed. After conservative measures failed for treatment of the hydroceles, the condition was treated during desired testicular relocation, and creation of a neoscrotum. In the case presented, bilateral thigh hydroceles may have developed from lymphatic injury during testicular transposition. To our knowledge, this is the first case report of bilateral hydrocele testis in the medial thigh pouches following ectopic testicular transposition.

UNLABELLED Craniectomy defects following resection of calvarial lesions are most often reconstructed using on-table manufacturing. With the advent of computer-aided design/manufacturing and customized craniofacial implants (CCIs), there seems to be more suited alternatives. In this study, the authors report their institutional experience and outcome using immediate, single-stage, CCI-based reconstruction for benign and malignant skull neoplasm defects. METHODS A retrospective review of a prospectively maintained database of all implant cranioplasties performed between 2011 and 2014, by a single craniofacial surgeon at a tertiary academic medical institution was performed. Preoperative and postoperative computed tomography scans with 3D reconstruction were performed for the purpose of assessing adequate resection and reconstructive outcomes. Primary endpoints included length of surgery, predicted defect versus postoperative implant surface area, contour irregularities, and complications. RESULTS Of the 108 patients with cranioplasty identified, 7 patients were found to undergo immediate CCI-based reconstruction for calvarial neoplasms; 4 patients (4/7, 57%) presented with malignant pathology. All defects were >5 cm2. As compared with their original size, all implants were modified intraoperatively between 0.2% and 40.8%, with a mean of 13.8%. With follow-up ranging between 1 and 16 months, there were no implant-related complications identified. The immediate and long-term aesthetic results, as well as patient satisfaction, were ideal. CONCLUSION With this preliminary experience, the authors have successfully demonstrated that immediate customized implant reconstructive techniques, by way of intraoperative modification, are both safe and feasible for benign and malignant skull neoplasms. The authors believe that with wider acceptance of this multidisciplinary approach and increased surgeon familiarity, this technique will soon become the reconstructive standard of care.

Importance In 2014, the US Department of Health and Human Services decided that its 1981 exclusion of transsexual surgical treatments from Medicare coverage was based on outdated, incomplete, and biased science and did not reflect current evidence or standards of care, and the exclusion was therefore lifted. As a direct result of this decision, surgeons nationwide are seeing an increase in consultations for surgical therapy to help transgender and gender-nonconforming individuals. Although some clinicians may have the technical training for such surgical procedures, in many cases, they may not have a full understanding of the complex and comprehensive care required to provide optimal health care for transgender individuals. Observations Gender confirmation surgery is a developing field in the United States and other areas of the world. The World Professional Association for Transgender Health started a global education initiative intended to provide surgeons and other health care professionals with the necessary background knowledge to understand and treat this patient population. This article provides an overview of best practices as set forth in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health, including mental health, endocrinology, and surgery for trans women and trans men. Conclusions and Relevance Experts in each aspect of transgender health have summarized the content of the global education initiative in this article. It provides valuable information to surgeons of all disciplines and other health care professionals to help guide the treatment and management of transgender individuals.

BACKGROUND: An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE: We report a single surgeon’s experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN: From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS: This study was conducted at an academic, tertiary-care cancer center. PATIENTS: Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS: Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES: The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS: Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS: The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION: This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).

Our aim was to identify the predictive factors for permanent pacemaker (PM) implantation in patients undergoing isolated aortic valve replacement (AVR). A total of 3534 patients received an AVR between January 1990 and December 2003 in our institution. Permanent PM implantation was performed in 234 (6.6%) patients, over median time of three days (range one to 24 days). This patient population was compared to a random sample of 191 patients undergoing AVR without permanent PM implantation. The overall mean age was 63.5 years (±14.2) and 261 patients (62%) were male. Univariate and multivariate logistic regression analysis of pre- and perioperative data were performed. Overall the 30 days mortality was 4.2% (10/234) in patients with PM and 1% (2/191) in the control group (P=0.046). Patients with PMs were older (P

The modern management of abdominal stab wounds remains controversial and subject to continued reappraisal. In the present study we reviewed patients with abdominal stab wounds to examine and validate a policy of selective non-operative management with serial physical abdominal examination in a busy urban trauma centre with a high incidence of penetrating trauma.Over a 12-month period (2005), the records of all patients with abdominal stab wounds were reviewed. Patients with abdominal stab wounds presenting with peritonitis, haemodynamic instability, organ evisceration and high spinal cord injury underwent emergency laparotomy. No local wound exploration, diagnostic peritoneal lavage or ultrasound was used. Haematuria in patients without an indication for emergency surgery was investigated with a contrasted computed tomography (CT) scan. Patients selected for non-operative management were admitted for serial clinical abdominal examination for 24 hours. Patients in whom abdominal findings were negative were given a test feed. If food was tolerated, they were discharged with an abdominal injury form.One hundred and eighty-six patients with abdominal stab wounds were admitted. There were 171 (91.9%) males, with a mean age of 29.5 years. Seventy-four patients (39.8%) underwent emergency laparotomy. There were 5 negative laparotomies (6.8%). The remaining 112 patients (60.2%) were assigned for abdominal observation. One hundred (89.3%) of these patients were successfully managed non-operatively. The remaining 12 patients underwent delayed laparotomy, which was negative in 2 cases (16.7%). Non-operative management was successful in 53.8% of patients overall. The overall sensitivity and specificity of serial abdominal examination was 87.3% and 93.5%, respectively.Serial physical examination alone for asymptomatic or mildly symptomatic patients with abdominal stab wounds enables a significant reduction in unnecessary laparotomies.