Iranian Journal of Surgery
Year:2007 | Volume:15 | Issue:2|Papers Count:25

There has been a worldwide increase of longevity in the recent decades. Statistically ischemic heart disease and other heart problems has also increased dramatically, and is said to be number one killer in industrial and semi-industrial countries. So any patient that undergoes surgery may have an active or silent coronary artery disease; this should be diagnosed and treated or guarded against preoperatively, the second distressing problem that may need treatment is pulmonary problems as the second more common postoperative complication. Other diseases that need to be recognized and treated preoperatively are diabetes mellitus; hypertension and renal disease. The increasing number of geriatric patients, besides their age; may have other comorbidities that need special attention and treatment, so is their nutritional status.Nutritional problem and cachexia makes them more susceptible to the stress and hypermetabolic state hat surgery can produce. So the surgeon should be aware of all the risks and complications that the patient can face with them.Some of the patients are on different medications that some should be continued, and some either stopped or replaced with other medications.It is quite rational that all surgeons have a good view of their patients' problems; so they could be  reated on time or be referred to other especialities for consultation and treatment. It is true that most of the patient’s comorbidities are in the field of other especialities; but the surgeon is on a whole, responsible for what happens to his patient and what would be the outcome of surgery. 

Introduction & Objective: Experimental studies in myelomeningocele (MMC) suggested that the primary malformation is not neural but neural tissue damage is acquired as a result of exposure of neural tissue to amniotic fluid (AF). In this study the effects of amniotic fluid on spinal cord and histopathologic changes in fetal sheep with MMC were evaluated.Materials & Methods: In an experimental clinical trial,10 fetal sheep in two group 5 cases and 5 controls were studied. In sheep at 90-100 days gestational age (term = 145-150 days) in lumbar area skin and paraspinal soft tissues excised and laminectomy was the performed at L2 – L4 and we opened duramater. In case group fetal sheep was dorsally with nonclosed dura and thus with open exposure of the spinal cord to amniotic fluid (AF) and in control group immediately the skin was closed. Lambs were delivered near term by cesarean section. They were assessed clinically and morphologically for paraplegia, paraparesia, urine and stool incontinency, pathology of spinal cord, thigh and rectal muscles and anal sphincter muscles. Results: In case group, all lambs (n=5) had a complete or incomplete flaccid sensorimotor paraplegia, were incontinent for urine and 4 animals were incontinent of stool but only one lamb in control group (n=4) had paraparesia (P=0.048) and all lambs were continent for urine and stool.In case group, all lambs had a hypoplastic longitudinal muscles in rectum but well developed circular muscles. Anal sphincter muscles did not develop normally but in control group all lambs had well developed longitudinal and circular muscles and anal sphincter muscles developed normally (P=0.008).Spinal histopathologic changes were edema, focal calcification, fibrosis and capillary cell proliferation in case group but in control group were not seen. The number of ganglion cells was significantly higher in the control group, comparing with case group (P< 0.0005). Conclusions: Exposure of MMC to AF, causes structural neural tissue damage that can be prevented by fetal surgery with repair of the MMC.

Introduction & Objective: Due to the recent advancement in the fields of antibiotic therapy, vaccination, and general health, there is a decreasing number of surgical interventions for the treatment of bronchiectasis. Considering the favorable advances in the field of lung surgery these days, it seems that physicians as well as patients are not acquainted with the surgical methods and the outcome of the surgical treatment of bronchiectasis. Therefore, we present and analyze our results in the surgical treatment of bronchiectasis and compare the results with medical treatment during the same period.Materials & Methods: The study population consisted of all patients who were referred to us (Masih Daneshvari Hospital) and hospitalized for the surgical treatment of bronchiectasis during 7.5 years (March 1999 to September 2006).Surgical or non-surgical treatment was selected according to the usual indications for the treatment of bronchiectasis. Response to treatment was evaluated by referring to the patients' medical records, and outpatient visits. The results were attributed as: Good: Sputum production and other major signs completely disappeared; Satisfactory: Although the signs and symptoms had not totally disappeared, the patient was satisfied with the treatment results; Poor: No significant changes were detected in the major signs and symptoms.Technique of surgery was posterolateral thoracotomy under one lung ventilation, and performing lobar or segmental resections. Medical treatment included physiotherapy, antibiotic administration and vaccination against influenza and pneumonococcus. Statistical analysis was performed by using Access and SPSS software. Fisher’s exact test and Chi-Square tests were used for qualitative comparison of the results. Mean duration of follow up was 35.9 months (range 1-96 months).Results: Total number of 83 patients were studied (48 females, 35 males, mean age 37.8 yrs, range 8- 1), 40 patients underwent surgery while 43 underwent medical treatment. The results of surgery were: good in 16 (55.2%), satisfactory in 10 (34.5%) and poor in 2 (6.9%) patients. The results of medical treatment were good in 4 (13.8 %), satisfactory in 11 (37.9 %), and poor in 13 (44.8%) patients. Good results were significantly better (P=0.002) and poor results were significantly worse (P=0.002) after surgical treatment. In each group, one death occurred during the treatment course. Fourteen patients in medical group and 11 patients in surgical group were lost from follow up.Conclusions: When indicated, surgical therapy offers advantages over medical therapy in the treatment of bronchiectasis.

Introduction & Objective: Appropriate management of extremity injuries results in limb salvage but such attempts in severe injuries may cause several complications. These complications are due to restoration of perfusion to ischemic tissues and include: respiratory failure, renal failure, decreased level of consciousness and decreased cardiac output. These can disturb managing patient, both intraoperatively and postoperatively.Thus predicting such events preoperatively, can help in better management.We are aiming at assessing outcome and complications of limb vascular repair operations, regarding MESS preoperatively.Materials & Methods: As a descriptive - analytic study, we evaluated all patients operated due to extremity vascular injuries during years 1995-2005.An score named Mangled Extremity Severity Score (MESS) was calculated for each patient, using certain clinical criteria including: skeletal/soft tissue injuries, limb ischemia, shock and age. Then patients divided into two groups: one with scores less than 7 and the other with scores ³ 7. Relative frequency was calculted for certain complications in each group and then the results were compared and analyzed statistically by Fisher's Exact Test.Results: Of 68 patients, 54 had MESS<7 and 14 had MESS ³ 7. Relative frequency of intraoperative complications, including hypotension, need to vasopressors, and acid - base disturbance were 50%, 14.3% and 92.9% in group with MESS ³ 7 and 13%, zero and 29.6% in group with MESS<7, respectively.Relative frequency of postoperative complications, including mechanical ventilation, delay in extubation, limb reoperation, limb amputation, mortality and cardiac arrest were 25%, 35.7%, 72.7%, 72.7%, 28.6% and 28.6% in group with MESS ³ 7 and 2%, 1.9%, 13.2%, 7.5%, 1.9% and 3.8% in group with MESS<7, respectively.Mean of bicarbonate and blood infused intraoperatively were 0.4 ± 0.9 vial and 3.3 ± 2.7 unit in group with MESS<7 and 2.4±3.3 vial and 7.3 ± 5.4 unit in group with MESS ³ 7, respectively. Mean of BUN and creatinine 24 hour after operation and duration of hospitalization were 18 ± 6mg/dl, 0.9 ± 0.3mg/dl and 8.8 ± 8.2 days in group with MESS<7 and 31 ± 14mg/dl, 1.6 ± 1.2mg/dl and 17.7+11 days in group with MESS ³ 7, respectively. There were no statistically significant difference in mean of fluids infused intraoperatively, relative frequency of acid - base disturbance and mean of GCS, both 24 hours after operation, comparing two groups.Conclusions: Relative frequency of complications in patients with MESS ³ 7 was significantly more than those with MESS<7 and limb salvage efforts, when not indicated, caused more severe complications and poorer prognosis.

Introduction & Objective: Acute mesenteric ischemia, an important cause of acute abdomen, develops due to a dramatic decrease in intestinal blood supply. According to different series, mortality rate ranges from 60 to 100 percent. This study reviews the clinical features, laboratory data, abdominal radiographs, preoperative ECG, intraoperative findings and treatment results in 32 patients admitted with a diagnosis of acute mesenteric ischemia, from March 1996 to March 2002 to Shohadae Tajrish medical center, Tehran, Iran. Materials & Methods: In a retrospective study we reviewed 32 patients admitted with a diagnosis of acute mesenteric ischemia at Shohadae Tajrish Medical Center, according to the data in their medical records. Results: The disease was twice as common in males as in females, with a mean age of 60 years at the time of presentation. Abdominal pain was the most common symptom followed by nausea, vomiting, obstipation, hematemesis and melena in decreasing order of frequency.On physical examination, most patients had tachycardia. Oliguria was present in 70% of patients and correlated with mortality rate. Shock was also encountered in 10% of cases with a close correlation with mortality. In 30% of patients, peritoneal signs were present which didn’t correlate with mortality. As laboratory findings, leukocytosis was encountered in 95 % of patients which exceeded 20000 / mm3 in 50 % of patients. Eighty percent of patients had acidosis. Overall mortality was estimated to be 75%. Conclusions: According to this study early attention to patient resuscitation, correction of metabolic and homodynamic abnormalities and expeditious surgery are essential steps for successful management of mesenteric ischemia. In selected cases a second look operation is warranted to re-evaluate the viability of the bowel.

Introduction & Objective: Significant postoperative pain, defecation problems and relatively long recovery period encouraged researchers to find a safe substitute for conventional Milligan – Morgan hemorrhoidectomy. This study shows the results of our experience with stapled hemorrhoidopexy as one of these methods.Material & Methods: From 1999 to 2005, 47 patients (31 male and 16 female) with an average age of 53 years underwent stapled hemorrhoidopexy in Arad General Hospital. All of these patients were prospectively evaluated for 6 months after surgery. The degree of hemorrhoids were grade 2 in 23.4%, grade 3 in 63.9%, grade 4 in 10.6% and one case of rectal prolapse.Results: The average length of operation was 38 min (30-60 min). Mean hospital stay was 1.3 days (1- 3 days). There was no intraoperative complication. The number of 4 cases (8.5%) was complicated: One case with rectal bleeding readmitted 48 hours after surgery. There was no pathologic finding in rectoscopy; after receiving 2 packed cell unit the patient was discharged. In 2 cases of reprolapse, one case was treated by sclerosing injection and the other by local resection of hemorrhoidal pile; and finally, one case with postoperative urinary retention and cystitis had history of urinary problems before the surgery. Neither functional nor incontinency to gas and liquids was presented with a mean follow up of 30 months. Overall of 85.1% (40 cases) of patients were fully satisfied.Conclusions: In spite of severe pain and discomfort and often a prolonged recovery period after conventional operation, stapled hemorrhoidopexy is an effective and safe alternative means of treating prolapsing hemorrhoid. Besides of decreased or eliminated postoperative pain, perioperative and late complications rate were also totally acceptable.

Introduction & Objective: Gastrointestinal perforation is one of the most important causes of emergent surgeries in surgery wards. On the other hand, mortality is high in this group because of underlying diseases and delay in diagnosis. Assessment of these patients is helpful especially in a tertiary care center. Materials & Methods: In a five-year period from 2002 to 2007, we reviewed clinical records of patients with gastrointestinal perforations from esophagus to rectum (excluding perforated appendicitis). Demographic data, underlying diseases, location, and causes of perforation and outcome of patients extracted and analyzed.Results: From 80 patients, 60 (75%) were male and 20 (25%) were female. Mean age was 51±19 years old. The most common causes of perforation were peptic ulcers (36%), trauma (17%), malignancy (15%), and iatrogenic due to endoscopic procedures (12.5%). In peptic ulcer subgroup, mean age was 52.6 year. Twenty two patients (81.5%) were male and five (18.5%) were female. There was no statistical difference in admission month and season in this subgroup. Site of perforation was stomach in 19 (65.5%) and duodenum in 10 (34.5%). Seven patient (24%) with perforated peptic ulcer expired. Mortality was not related with history of gastrointestinal disease, smoking, alcohol consumption, opium addiction, NSAID or corticosteroid use, and ischemic heart disease. There was no association between mortality and leukocyte count, perforation size, and time from symptoms to surgery; but mortality was significantly associated to underlying disease (PValue = 0.041) and patients with underlying disease were older than others (P<0.005).Conclusions: The most common cause of gastrointestinal perforation (excluding perforated appendicitis) is peptic ulcer disease, which is more common in males. The most related factors with mortality was the presence of underlying disorders which are more in the older. This shows importance of proper diagnosis in geriatric patients. In centers with frequent diagnostic and therapeutic endoscopic procedures, iatrogenic gastrointestinal perforation is among common causes of perforation.

Introduction & Objective: It remains controversial whether transcervical thymectomy offers results equivalent to thymectomy by way of median sternotomy in the treatment of myasthenia gravis. Furthermore preoperative prognostic factors have not been clearly defined.Materials & Methods: This study is a retrospective chart review and interview of 37 patients completing transcervical thymectomy for myasthenia between 1996 and 2003 out of age, sex, drug resumption, operation time and complication were studied. Data were analyzed by Kaplan-Meier test and P<0.05 was significant.Results: From 37 patients, there were 65.8% women. Mean of age (±SD) was 31.36±10.4. There was no preoperative mortality, we had morbidities in 10.8% of patients.Mean length of stay was 5.5±1.44 days and mean follow up time was 35.39±20.44 months. The crude cumulative complete remission was 11.7%. Kaplain - Meier estimates of remission were 70.6% and 85.3% at 2 and 5 years, respectively. The significant relation was present between pathology of thymus, type of drug resumption before-operation and remission.Conclusions: Overall, extended transcervical thymectomy offers results that are comparable to those published for transternal procedure. Also, there is controversial about preoperatively predictor factor for remission.

Introduction & Objective: The patency rates of a radial artery graft for CABG approximate 80% at 7years, although significantly higher patency rates have been reported. Placement of the radial artery graft onto a left-sided target vessel with a high-grade proximal stenosis and good runoff may result in higher patency rates. We evaluated radial artery as a suitable conduit for CABG and measured its early and mid-term results in our 5 years experience.Materials & Methods: From August 1999 to June 2006 radial artery graft was used for CABG in 308 patients. We never dilate radial artery with intraluminal injection. Early and mid term complications and clinical outcomes were evaluated in these patients with a mean follow up of 21±6.2 months. Allen test was performed before operation in all patients.Results: The number of 308 patients (240 male and 68 female) undergoing CABG had one (286) or two (22) distal anastomosis from radial graft conduit in addition to other conduits, patients’ mean age was 55±4.8 years (26-78). The number of 96% of the operations was elective and 4% were urgent. An average of 3.5 grafts per patient was performed. In 18% of the patients, total arterial conduit was used. The operative morbidity was re-operation for bleeding in 2.3%; post-operative-MI in 3.2%; parenthesis in the hand in 10%; stitch abscess in the hand in 3.5%. Mean x-time was 46±9 minutes and the mean CPB time was 85±11 minutes. Hospital mortality was in 0.6% (in 2 patients), in one case directly due to complication of harvesting of radial artery. During the follow up, all the patients are alive, free from cardiac events and have good function classes. Conclusions: Early and mid term results of CABG with radial artery conduit is excellent, and we recommend angiographic studies to establish the true long-term patency of radial artery.

Introduction & Objective: Post-intubation tracheal stenosis is a serious but preventable complication of endotracheal tubes, seen more as a problem, by developing ICU's and critical care. The aim of this study is to evaluate these stenoses in elderly patients regarding, etiologies, modes of treatment, prognosis and results.Materials & Methods: This retrospective clinical trial reports, the causes, therapeutic options and prognosis of these patients regarding "age" as a single comparative criteria. The patients were referred to our center during 13 years (1994-2006) and regarding their condition, have had different therapies.Results: It seems that in the elderly patients, general diseases (i.e cardiovascular, respiratory, neurologic, …) are the major causative agents making prolonged intubation necessary, not multiple trauma as in youth. Modes of therapy are more conservative and prognosis depends on the primary disease. Conclusions: Regarding general condition and primary diseases, surgery is still a main option for treatment of post intubation tracheal stenosis in elderly, although it is less feasible.

Introduction & Objective: One of the rapid ways for transporting patients in emergency situation is air transport. In the following study, we will discuss about the results of this kind of transport in Esfahan Province. Materials & Methods: In a retrospective study, all trauma patients that were transported to Al–Zahra University Hospital by helicopter since 2004 were investigated. Also, the information consisting of different transporting times, the kind of trauma, the geographical area of accident, the severity of trauma, patient transport indication and the result of transport were evaluated.Results: Approximately 46.15% of transport was done from Meimeh. Limb fracture and head injury have been the most prevalent trauma. The average time: before air transport: 8.72±8.9 min; halting at accident place: 3.67±12.24 min and after transport, it was 5.14±5.5 min.The whole time of transport in 23.08 % of the cases was less than 60 min. Among 36 patients, 6 cases died, one during the flight and five after transport in CPR room.Conclusions: Helicopter is a suitable vehicle for patient transport in distances less than 100 km. We will investigate the indication of air transport by helicopter in adults, children and the burn patients. Then, we will discuss about the interdictions of the transport by helicopter and the technique of patients' triage for air transport. Moreover, we will present the recommendations about the improving the air transport.

Introduction & Objective: These days, the majority of women who are undergoing mastectomy can also have breast reconstruction. Implants and latissimus dorsi flaps are some kinds of surgery that can be performed. The development of Transverse Rectus Abdominis Myocutaneous (TRAM) flap, enabled surgeons to use it, extensively for breast reconstruction. The main aim of this study was determination of the prevalence of different reconstructive surgery in Iran, find out advantages and disadvantage of these procedure and also evaluation of satisfaction of the patients.Materials & Methods: In a descriptive and cross-sectional study 148 patients, undergoing breast reconstructive surgery during 14 years, were evaluated. Their demographic data, age, kind of surgery gathered from their medical files. Then they followed for 5 years and complication of surgery and their satisfaction were evaluated. Data analyzed with SPSS software.Results: The most kind of surgery was TRAM flap 127 (86.3%) then was tissue expanders, implants, respectively; Fat necrosis 13 (8.7%) patients, seroma in 12 (8.1%) patients were the most complication of TRAM flap surgery.Satisfaction of patients were excellent in 31%, 25% respectively for breast and abdomen reconstructive surgery.Conclusions: This study suggests that the TRAM flap for breast reconstruction is a safe and reliable technique which provides an excellent cosmetic outcome with a high degree of patients satisfaction.

Introduction & Objective: Elevation of the skin with its deep fascia vascular network is a recent facility for flap design. Longitudinal trapezius fasciocutaneous flap introduced primarily at 1996 but did not receive enough attention, although it has many significant benefits comparing to the other available procedures.Materials & Methods: Sixteen trapezius fasciocutaneous flaps were used in 15 patients for severe scarring of the neck and mid face reconstruction. All flaps were based on the deep branch of the transverse cervical artery and included overlying fascia of trapezius muscle. Delaying was applied for very long flaps. Results: Two flaps developed minimal distal necrosis(less than 5 cm) due to longer pedicle (more than 10 cm below the muscle border).The result indicates that the extra-long, back fascia flap based on descending branch of transverse cervical artery could be formed long enough to reconstruct whole neck and safely transferred to mid face.Conclusions: The vertical trapezius fascio-cutaneous flap with its abundant tissue, excellent blood supply and anatomic proximity with wide arc of rotation and hidden donor site scar, provides a simple and reliable method for primary reconstruction of various mid - face and neck defects.

Introduction & Objective: The aim of this study was to give some information about burns that occur in children and adolescents. Materials & Methods: The subjects were 1014 patients that were younger than 15 years who were treated at one burn center in Esfahan. The data collected for each case were age, gender, place of residence, cause and extent of burn, hospitalization status and mortality.Results: The 1014 patients comprised 45.5% of all 2229 burn victims admitted during the study period. There were 610 boys and 404 girls (ratio 1.5:1). The highest proportion of patients was in the 3–6 years age group. Hot water scalding (526 cases, 51.8%) was the leading burn cause. The number of 667 (65.7%) subjects lived in urban environments and 346 (34.3%) lived in rural areas. The overall mortality rate was 5.5% (56 deaths).Conclusions: The features of burns among children and adolescents differ from region to region. Every country needs a nationwide public education system aimed at preventing burns and ensuring that young burn victims receive first aid and burn care that is specific to their needs.

Introduction & Objective: The incidence of esophageal cancer is 3 times higher in men than in women and its prognosis is better for women than men. Furthermore, experimental animal models investigations about sex hormone receptors and tumoral growth, supports possible implication of sex hormones in esophageal cancers. This study aimed to evaluate estrogen and progesterone receptors in esophageal squamous cell carcinoma and their relation with patients’ survival.Materials & Methods: In this study 100 cases of non-metastatic esophageal carcinoma (50 males & 50 females), which underwent radical esophagectomy in Shohadaye Tajrish, Taleghani, Imam Khomeini and Baghiyatallah hospitals, included. Receptors identified by Labeled Strep Avidin Biotin (LSAB) method and relationship between presence of receptors and sex, tumor stage, tumor location and patients survival evaluated. Data analysis performed using chi-square, t-test, Fisher’s exact test and survival analyzed with Kaplan-Meier and log rank tests. P-values <0.05 considered statistically significant.Results: Estrogen receptors (ERs) found in none of cases and progestron receptors (PRs) were positive in 14% of cases. In PR positive cases proportion of females was 25% higher comparing to PR negative cases (P=0.08). Age of PR positive patients ranged from 40-79 years with average of 54.7±12.1 years and age of PR negative patients ranged from 32-85 with average of 59.4±11.8 years (P=0.1). There were no significant difference in sex, tumor location, lymph node involvement, depth of invasion, and tumor grade between PR positive and PR negative cases (P>0.05). Average survival time of PR positive cases was 15.8 months and in PR negatives was 10.3 months (P=0.68).Conclusions: There was no estrogen positive case in this study and progesterone receptors were positive in few cases. There were no statistically significant relation between prognosis of patients and tumor specifications and presence of progesterone receptors in this study but further larger studies are suggested in this regard.

Introduction & Objective: Pediatric surgeons and urologists when facing children with elimination disorders often listen to their parents for information regarding their toileting. Primary school teachers can be potential counselors that recognize and help children with dysfunctional voiding. Their lack of knowledge, on the other hand can worsen these children’s conditions. The purpose of this study was to assess the knowledge of the primary school teachers about the voiding dysfunction of students in west azerbaijan province. Materials & Methods: The subjects of this study consisted of 101 primary school teachers with a mean age of 41±6.77 years from 12 schools in City of Urmia which were selected through multiple cluster sampling. In each selected school, all teachers completed a 21-item Farsi questionnaire, its validity and reliability had already been approved by our previous studies. All questionnaires were returned filled. Statistical tests were performed by Fisher’s exact, Mann-Whitney and Kruskal- Wallis tests.Results: Forty school teachers stated they had received some information about abnormal voiding and stooling. Only 9 teachers noted that their school does not have a school nurse. Ten teachers would pay a visit to students’ toilets once a day, but 80 teachers would almost never do that. Median number of toilets per school was 10 (1 to 12). As to the toilet sanitation, 19 teachers stated that they are “always clean”, 32 said that they are “clean at the start of the day”, 32 believed that “they become dirty progressively” and 18 said that they are “never clean”. In teachers’ opinion, short break time was the main reason for a permission to go to the toilet during class time, followed by the insufficient number of toilets, and as an excuse to leave the class.Forty-six teachers would offer set-times other than the breaks for the students to go to the toilet. In response to this question that what would you do if a student asked for the permission to leave during the class, 69 said they will grant the permission, 21 said they would rather ask to wait, 4 said they will accompany him/her to the toilet and only 6 said they would let the students leave on their will. As to the teachers’ attitude regarding the urinary frequency, urinary and fecal incontinence, 15, 24 and 26 of them had never encountered these problems, 28, 19 and 17 would notify the parents, and 44, 48 and 42 would notify the school nurse.Conclusions: The elementary school teachers’ attitude towards the abnormal voiding and stooling is not appropriate and informed. It seems that acquisition of information is gradual and by experience. Adding educational material regarding pediatric bladder and bowel function to primary school teachers’ college curriculum can shorten their learning curve and prepare them to confront these problems more efficiently. Pediatric surgeons and urologists and other primary care physicians can use the elementary school teachers knowledge for the benefit of more effective treatment plans.

Introduction & Objective: Traditional augmentation cystoplasty using gastrointestinal segments is known to be associated with metabolic abnormalities and alterations in the bladder causing potential carcinogenesis. In this respect alternative techniques have been searched preferably lined by urothelium. We performed retroperitoneal ureterocystoplasty in 3 patients with a diagnosis of neurogenic bladder and investigated the clinical and functional aspects.Materials & Methods: Three patients, 2 male and 1 female patients with neurogenic bladder and bilaterally functional kidneys were selected. All the patients were incontinent, had a small-capacity, noncompliant bladder, and high-grade reflux on voiding cystouretrography (VCUG). Urodynamic study was performed in all. Retroperitoneal ureterocystoplasty using distal end of both ureter in 2 patients and one ureter in other patient was performed. Postoperatively all patients were followed with voiding cystourethrography(VCUG) after one month and bladder capacity measured.Results: Median age was 20.3 years (18-22). Preoperative serum creatinine was 2.3, 2.4 and 2.7 mg/dl and preoperative bladder capacity was 100, 70 and 55ml. The operative duration for the procedure was 3, 2.5 and 2.5 hours. The postoperative course was uneventful. Mean hospital stay time was 6.7 days. All patients were dry by day with clean intermittent catheterization. Serum creatinine was 1.2, 1.6 and 1.9 mg/dl one month postoperatively. Bladder capacity was increased to 340, 360 and 290 ml.Conclusions: The early results of ureterocystoplasty compare favourably with those of enterocystoplasty without the risks of long-term metabolic and neoplastic complications. Augmentation ureterocystoplasty has the beneficial effects of enterocystoplasty without the complications that may arise from the use of bowel segments.

Introduction & Objective: Shoulder dislocation is one of the most common dislocations of large joints and anterior type is the most common type of it. Inferior shoulder dislocation is a rare type. There are few reported cases about this kind of dislocation so complications and results of it are not fully understood.Materials & Methods: A 40 year old man who injured in a car accident, has been referred to emergency room. His arm was held in the position of abduction and external rotation. He had refractory hypotension which needed emergent spelenectomy. In the same anesthesia we reduced his shoulder dislocation but the fractured greater tuberosity did not reduced completely to its anatomic position was not normal and also it seemed to be intraarticular and caused joint incongruity; so after several days and after the patient became stable, open reduction and internal fixation of greater tuberosity of humerus were done. Conclusions: Because of rarity of inferior dislocation of shoulder, we cannot compare inferior shoulder dislocation with anterior shoulder dislocation (which is more common) in their complications and results, but it seems that higher energy trauma is needed to cause inferior dislocation of shoulder and also direction of dislocation of head causes more injury to adjacent soft tissues, so after reduction of shoulder, the chance of anatomic reduction of greater tuberosity of humerus is low in this type and the need for surgery is higher.