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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 26 | Issue 1
Page Nos. 1-94

Online since Monday, February 10, 2020

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REVIEW ARTICLE  

Investing in pediatric surgical research to advance universal health coverage for children in Nigeria p. 1
Justina O Seyi-Olajide, Emmanuel A Ameh
DOI:10.4103/njs.NJS_43_19  
About 1.7 billion children and adolescents most of whom are in low- and middle-income countries lack access to safe and affordable surgical and anesthesia care when needed. 43% of Nigeria's population of 199 million are below the age of 15 years. In 2015, Nigeria had a pediatric surgeon workforce deficit of 693 for children <15 years. While threats and constraints to achieving universal health coverage in Nigeria have been highlighted, the role of research is often not included. Over the years, there has been a slow but progressive increase in pediatric surgical workforce and research output, both locally and with international collaborations, and in trainee involvement in research as lead authors. There has unfortunately been a challenge with translation of research findings, outcomes, and recommendations into actions. Despite the various challenges mitigating against pediatric surgery research, efforts must be committed to developing and implementing innovative approaches to address the problems and challenges, as well as implementing quality improvement programs and deploying technology to advance children's care. It is hoped that inclusion of children's surgery in the National Surgical, Obstetrics, Anaesthesia, and Nursing Plan would strengthen pediatric surgical research in Nigeria.
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ORIGINAL ARTICLES Top

A study correlating the tumor site and size with the level of axillary lymph node involvement in breast cancer p. 9
Prem Chand, Savijot Singh, Goldendeep Singh, Shivanshu Kundal, Anil Ravish
DOI:10.4103/njs.NJS_47_19  
Background: Breast cancer is the leading cancer in women. The most common histologic type of breast cancer is infiltrating ductal carcinoma. The mainstay of the treatment of breast cancer is surgery when the tumor is localized, followed by chemotherapy as well as radiotherapy (when indicated) and in estrogen receptor and progesterone receptor positive tumors, adjuvant hormonal therapy. Aims and Objectives: The aim of this study is to correlate tumor site and size with the level of axillary lymph node involvement (ALNI) in early and locally advanced breast cancer. Materials and Methods: This prospective and observational study was conducted on fifty female patients of carcinoma breast with early and locally advanced breast cancer. Results: The age distribution showed two peaks at 41–50 years and 51–60 years with 42 and 24 patients, respectively, in both the age groups. Preoperative lymph node positivity by ultrasonography matched with postoperative histopathological examination (HPE) report. Preoperative ultrasonographically determined tumor size was similar to the final histopathological T stage. Conclusion: As size of tumor increases, there is an increase in ALNI which suggests that nodal metastasis is indicative of tumor chronology. Ultrasonography is a good tool to objectively measure tumor size and lymph node involvement preoperatively. Quadrant of involvement can emerge as a clinically useful prognostic cancer in breast cancer as there is a higher incidence of lymph node positivity with increasing size of the breast tumor and for tumors located at the upper outer quadrant of the breast.
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Comparative study of alvarado score and its modifications in the preoperative diagnosis of acute appendicitis at a tertiary center in Sokoto, Nigeria p. 16
Muktar Muhammad Umar, Ibrahim Umar Abubakar, Stephen P Agbo
DOI:10.4103/njs.NJS_46_19  
Background: Decision-making in patients suspected of having acute appendicitis has remained a diagnostic challenge worldwide despite the advances in imaging and appendiceal surgery. There have been efforts to improve the diagnosis of appendicitis using clinical scoring systems. Aim: We evaluated and compared the diagnostic accuracy and role of Alvarado score (AS) and two of its modification (Kalan and Al-Fallouji) in the preoperative diagnosis of acute appendicitis. Materials and Methods: This was a prospective study conducted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, of all adult patients operated for acute appendicitis from July 2014 to June 2017. The results were analyzed on computer using Statistical Package for the Social Science version 15.Results: One hundred and eleven patients were studied. Sixty-six (59.5%) patients were males and 45 (40.5%) were females. The male-to-female ratio was 1.5:1. The mean age was 23.89 ± 4.93 years. The AS sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 90.3%, 83.3%, 96.6%, 62.2%, and 89.2%, respectively, were similar to the findings of Kalan score (90.3%, 83.3%, 96.6%, 62.5%, and 89.2%, respectively) and Al-Fallouji score (96.8%, 66.7%, 93.8%, 80%, and 91.9%, respectively). The receiver operating curve and area under the curve show that Alvarado, Kalan, and Al-Fallouji are accurate scores in the preoperative diagnosis of acute appendicitis with an area under the curve of 0.88, 0.86, and 0.85, respectively. Conclusion: Kalan and Al-Fallouji scores have comparably good diagnostic accuracy as the AS among our patients. Any of these scores can be used as an adjunct in the preoperative diagnosis of acute appendicitis.
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Influence of implant neck design on crestal bone loss: A comparative study p. 22
Yojana B Patil, Swati Joshi Asopa, Deepa , Aashana Goel, Divya Jyoti, Nagaveni S Somayaji, Robin Sabharwal
DOI:10.4103/njs.NJS_28_19  
Background: The success rate of dental implants depends on the amount of crestal bone around the implants. Crestal module is the transosteal region of implant that is designed to receive the prosthetic component. The design of crestal module influences the crestal bone loss around implants. Aim: The purpose of this study was to evaluate and compare the crestal bone loss around implants with smooth collar and implants with micro threaded rough collar design. Materials and Methods: A total of 150 individuals received 100 dental implants. Each individual received one implant with smooth collar design (Group-A) and one implant with microthreaded rough collar design (Group-B) in the posterior edentulous region. All the 100 implants were prosthetically loaded after a healing period of 3 months. Crestal bone loss was measured on mesial, distal, buccal, and lingual side of each implant using periapical radiographs before loading (baseline), immediately after loading, 6, and 12 months after loading. Results: The average crestal bone loss 12 months after loading the implants in Group A and Group B was 3.75 mm and 3.23 mm, respectively, the value being statistically significant (P < 0.05). In both Group A and Group B, the average crestal bone loss was maximum on the lingual side followed by buccal, distal, and mesial sides. Conclusion: Crestal bone loss around rough-surfaced microthreaded neck implants was significantly lower than smooth-surfaced neck implants.
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Incidence and Pattern of Extremity Fractures seen in Accident and Emergency Department of a Nigerian Teaching Hospital p. 28
Njoku Isaac Omoke, Francis Oji Ekumankama
DOI:10.4103/njs.NJS_42_19  
Background: Extremity fracture is an important component of musculoskeletal injury worldwide. The distributions of etiological factors and types of extremity fractures vary from and within subregions and have implications in preventive and treatment strategies. This study aimed at determining the incidence and pattern of extremity fractures seen in accident and emergency department (A and ED) of a teaching hospital in a developing country. Patients and Methods: This was a prospective study of all patients with extremity fractures seen in A and ED of Federal Teaching Hospital Abakaliki over 12 months between February 1, 2016 and January 31, 2017. Results: Extremity fractures necessitated visit in 251 patients with 306 fractures giving an incidence of 22.6/1000/year of A and ED attendances (39.2/1000 males and 9.2/1000 females), with age range of 2–90 years and a mean of 35.6 ± 16.7 years. Road traffic accident (RTA) (184, 73.3%), fall from height (23, 9.2%), and gunshot (13, 5.2%) were the three top causes of fractures, whereas tibia, femur, and humerus were three top bones involved. Of the 306 fractures, 270 (88%) involved the long bones, 193 (63.1%) were close, and 113 (36.9%) were open fractures. Forty-four (17.5%) of them were multiply injured patient and head injury in 32 (12.8%) the topmost associated injury. One hundred and ninety-four (77.3%) were admitted into surgical ward and 28 (11.2%) self-discharged against medical advice. Conclusion: Appropriate preventive mechanisms based on the observed pattern is needed; a policy response to curb the menace of RTAs may invariably reduce the incidence of extremity fractures. Treatment strategies entail appropriate facilities and skilled workforce to deal with fractures of varying degrees of severity and complexity observed.
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The role of fine needle aspiration cytology in triple assessment of patients with malignant breast lumps p. 35
A Ugwu-Olisa Ogbuanya, S Nnamdi Anyanwu, E Festus Iyare, C Gregory Nwigwe
DOI:10.4103/njs.NJS_50_19  
Background: Breast cancer is the leading female malignancy in the world and now the most common cancer in Nigeria. The evaluation of patients with breast cancer requires stepwise diagnostic approach to achieve a combined diagnostic information required to make an enhanced decision on how best to approach management. The aim of this study is to evaluate the role of fine needle aspiration cytology (FNAC) in the triple assessment of patients with malignant breast lumps in our center. Patients and Methods: This is a descriptive prospective study of patients with palpable breast lumps over an eighteen-month period. The patients were sequentially subjected to FNAC and open biopsy. Those whose lumps were malignant were further evaluated. Results: There were 88 (44.9%) and 108 (55.1%) biopsy confirmed breast cancers and benign lumps, respectively. From cytology reports, there were 12 (6.1%) unsatisfactory (C1), 96 (49%) benign (C2), 8 (4.1%) atypical (C3), 10 (5.1%) suspicious of malignancy and 70 (35.7%) unequivocally malignant (C5) smears. FNAC performed better than clinical examination in the validity tests for breast malignancy. The diagnostic results for breast malignancies were 97.2% (sensitivity), 98.9% (specificity), 1.4% (false positive rate []), 2.1% (false negative rate), 98.6% (positive predictive value), 97.9% (negative predictive value), and overall diagnostic accuracy of 98.2%. Conclusion: Considering the high performance of diagnostic cytology noted above, FNAC has proved itself to be useful and significantly accurate in making diagnosis of breast cancers in our center.
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Postoperative pain management in emergency surgeries: A one-year survey on perception and satisfaction among surgical patients p. 42
AbdulGhaffar A Yunus, Euphemia M Ugwu, Yunusa Ali, Ganiyat Olagunju
DOI:10.4103/njs.NJS_18_19  
Background: Postoperative pain varies from an individual to individual. It also varies with types and extent of surgery. In general, postoperative pain is inadequately managed in most centers worldwide, especially in developing countries. Therefore, this study presents the perception and satisfaction of postoperative pain management in emergency surgeries. Methods: A 1-year prospective study of the 891 patients who underwent emergency general surgeries at Ahmadu Bello University Teaching Hospital, from January to December 2018 is hereby presented. Pain scores and patient's satisfaction toward postoperative pain management were considered at 8 and 24 h postoperatively through a predesigned questionnaire. Numeric Pain Rating Scale was used to determine pain intensity and the level of satisfaction following postoperative pain management. Student's t-test was used to compare the pain scores and patient's level of satisfaction of the postoperative pain management. Results: A total of 891 patients were recruited for this study, with a mean age of 36.4 ± 8.9 years with a male-to-female ratio of 1.3:1. Postoperative pain management satisfaction score for patients (98%) who had pain 8-h postoperative period was 4.8 ± 1.6. Similarly, 96.4% of the patients who had pain 24 h postoperatively scored 2.8 ± 1.7. Majority of the patients 481 (54%) were of the American Society of Anesthesiologist physical Class II. Most of the patients underwent general surgery using the technique of general anesthesia. Conclusion: This study indicated that the perception and level of patient's satisfaction regarding postoperative pain management are inadequate. The health professionals and policy makers should be aware that postoperative pain management is suboptimal, as patients still have severe postoperative pain. Therefore, the need for improved postoperative pain management.
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Binding pancreaticojejunostomy: Is it safe? p. 48
Sanjay Gupta, Ashok K Attri, Rajeev Sharma, Monika Gureh, Md Imran Nasir
DOI:10.4103/njs.NJS_17_19  
Background: Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ. Methods: The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality. Results: A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality. Conclusion: BPJ is safe and is associated with a low incidence of POPF.
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Prevalence, awareness, and factors associated with noise-induced hearing loss in occupational motorcyclists in Southwestern Nigeria p. 53
Shuaib Kayode Aremu, Rasaq Kayode Adewoye, Alao Taiye Adeyanju, David Sylvanus Ekpo
DOI:10.4103/njs.NJS_26_19  
Background: There is generally a lack of awareness among professional motorcycle riders on the risk of noise-induced hearing loss; due to a variety of factors, they are exposed to by the nature of their job. This study, therefore, aimed to determine the prevalence, awareness, and factors associated with noise-induced hearing loss among motorcycle riders in Ido-Ekiti, Ekiti State, Nigeria. Methodology: A cross-sectional descriptive study was conducted between February and March 2019 among 420 motorcycle riders in Ido-Ekiti, Ekiti State, Southwestern Nigeria. Data analyses were performed using the SPSS software version 20. P≤ 0.05 was considered as statistically significant. Three hundred and sixty of the total of 420 consented for pure-tone audiometry which was done to assess their hearing thresholds. Results: Majority of the respondents had at least a secondary level of education. About 14.5% of the total study population had hearing loss, among which 15% also reported an accompanying ear discharge. All of the respondents did not have any history of hearing loss before they started the occupation. More than half of the study population was aware of noise-induced hearing loss and was able to link it to their profession. None of the study participants used a hearing aid, but 17.9% reported using ear mufflers and 16.2% used earphones while riding. Conclusion: Majority of our respondents had secondary school education and 14.5% of the total study population reported hearing loss, among which 15% also reported an accompanying ear discharge. Furthermore, more than half of the study population was aware of noise-induced hearing loss and was able to link it to their profession, whereas 50% agreed that their occupation placed them at risk of hearing loss.
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“Tracheomalacia after Thyroidectomy,” Does it truly exist? p. 59
Neda Valizadeh, Peyvand Mohammadi, Rahim Mahmodlou, Seyed Arman Seyed Mokhtari, Gohar Ramezani
DOI:10.4103/njs.NJS_31_19  
Aim: Tracheomalacia is a potentially life-threatening, but a rare complication of thyroidectomy. In previous studies, the incidence rate was very different. Considering the relatively high prevalence of goiter and thyroidectomy in the West Azerbaijan region, we designed this study to determine the tracheomalacia incidence in patients who underwent thyroidectomy within a 10-year interval. Materials and Methods: This retrospective study was done in Urmia Imam Khomeini Hospital in West Azarbayjan Province. Demographic characteristics including the age and sex of patients who underwent thyroidectomy between 2007 and 2017 and also the incidence of tracheomalacia after surgery were recorded. Results: From 2007 to 2017, total 1236 thyroidectomy were performed. The patients' age ranged from 15 to 83-year-old with a mean age of patients was 44.5 ± 13.81 years old. Two hundred and twenty-nine patients (19%) were male and 1007 (81%) were female. We did not find any cases of tracheomalacia after thyroidectomy in our study population. Conclusion: Based on the results of this study, it seems that with the necessary precautions, the incidence of tracheomalacia can reach zero.
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Adult intussusception at a tertiary care center: A retrospective study p. 63
Sulfekar Meera Sainaba, Aravind S Ganapath, Anoop Sivakumar, AV Gayathri, IP Yadev
DOI:10.4103/njs.NJS_38_19  
Background: In adults, the majority of cases of intussusception are due to malignancy. Aims: The aim of the study is to describe the pattern of intussusception in the adult population diagnosed and treated at a tertiary care center. Subjects and Methods: Study Design: This is a retrospective cross-sectional study based on chart review, and data collection was made from the computer database and inpatient case records. Study Setting: Adult intussusception cases diagnosed and treated at a tertiary care referral center in South India. All inpatient case sheets including investigations and histopathology information on the computer database of all patients diagnosed with intussusception in the period of August 2012 to July 2016 were retracted based on a pretested and standardized form. Demographic data and other baseline data were summarized with descriptive statistics. SPSS software was used for data analysis. Results: Of the 77 patients, 47 (61%) were male. The common presentations were abdominal pain (95%), vomiting (64%), and rectal bleeding (29%). Common examination findings were abdominal tenderness (45%), guarding (39%), and abdominal mass (38%). On ultrasonography, fifty (65%) patients had intussusception with ileocolic (25) as the most common type. Computed tomography abdomen was taken for 28 (36%) patients, in which 23 (82%) had intussusception with ileocolic (9) as the most common type. Surgery was done for 53 (69%) patients, and the most common procedure was right hemicolectomy (25) followed by resection and anastomosis of the small bowel (23). Intraoperatively, 42 (79%) patients had intussusception with ileocolic (23) as the most common type. Intraoperatively, 14 (26%) patients had a bowel gangrene. Biopsy-proven cause for intussusception was present in 46 patients, with malignancy (21) as the most common cause. The patients were on regular follow-up. Recurrence of intussusception occurred in six patients of the small bowel intussusception who had polyposis. Conclusions: Adult intussusception is often associated with malignancy. Hence, a formal resection without reduction is needed and surgery should be done following oncological principles.
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Factors determining diabetic remission after sleeve gastrectomy: A prospective study p. 66
Rohit Jindal, Mayank Gupta, Ashish Ahuja, Prabhdeep Singh Nain, Pranjl Sharma, Aayushi Aggarwal
DOI:10.4103/njs.NJS_9_19  
Background: An exponential rise in the prevalence of obesity and the associated type 2 diabetes mellitus (T2DM) has led to an explosion in the field of bariatric surgery worldwide. It has been proposed that laparoscopic sleeve gastrectomy (LSG) not only results in excess weight loss (EWL) but also leads to excellent glycemic control. Aims: However, not every patient benefits from the bariatric surgery. Furthermore, bariatric surgery is currently indicated based on body mass index (BMI), but BMI solely does not predict diabetes remission after the surgery. We aimed to study the outcome of LSG on the diabetic status and the factors predicting the disease remission. Subjects and Methods: This prospective study was conducted on 104 obese patients having T2DM who underwent LSG. Following surgery, the clinical outcome on weight loss, BMI, and glycemic control was studied for 6 months. Various positive and negative predictors of diabetic remission after the surgery were also determined. Student's t-test and Chi-square tests were applied. Results: LSG resulted in significant weight loss (P < 0.05); the percentage of EWL was 60.75 ± 6.30 at 6 months. Furthermore, surgery resulted in 78.9% remission of diabetes with fasting blood glucose and glycated hemoglobin values at 6 months being 121.13 ± 15.25 mg/dl and 6.19% ± 0.31%, respectively. Younger and heavier patients, those with lesser disease severity and shorter duration had better chances of disease remission. Gender had no correlation with disease remission. Conclusion: LSG is a successful treatment option for T2DM and is more beneficial if offered, not as a last option, but to younger, obese patients with mild disease severity and shorter disease duration after the failure of medical treatment.
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CASE REPORTS Top

Situs ambiguous anomaly during laparoscopic cholecystectomy in an adult female p. 72
Brij Mohan Joshi, Sumitoj Singh, Ashok Kumar, Mandeep Singh Sandhu, Deepak Rana
DOI:10.4103/njs.NJS_47_18  
Situs anomalies are rare structural defects affecting 0.01% of general population. They present with multisystem structural defects mostly involving cardiovascular, respiratory and GI systems. Situs abnormality with presence of multiple spleen is termed as left atrial isomerism with anatomical and structural differences to its countertype situs ambiguous with asplenia (right atrial isomerism). In this case report, we present an adult case of situs ambiguous anomaly which was diagnosed incidentally during laparoscopic cholecystectomy. The patient had enlarged left lobe of liver, multiple splenules on right side, malrotated small and large gut, interrupted inferior vena cava with azygos continuation, and bilateral bilobed lungs. It is concluded that variations in situs ambiguous cases differ and a single description is not possible. It is crucial to reveal these variations by using imaging modalities and being aware of them prior to surgery and invasive intervention to prevents the possible risks and complications.
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Laparoscopy-assisted transanal endorectal pull-through for the management of hirschsprung's disease in Nigeria: Report of two cases p. 78
Adesoji O Ademuyiwa, Olumide A Elebute, Olanrewaju S Balogun, Ibironke Desalu, Lohfa B Chirdan, Christopher O Bode
DOI:10.4103/njs.NJS_39_18  
Hirschsprung's disease is a relatively common disease in pediatric colorectal surgery. The treatment modalities have evolved from third-stage to single-stage in the past three decades. The single-stage procedure can be performed using the open, transanal or laparoscopy–assisted techniques. We use these cases to illustrate the first laparoscopically assisted procedures for Hirschsprung's disease in our center. The laparoscopic-assisted technique is described, and lessons in collaboration across institutions and within institutions are discussed.
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Pemphigus in sarcomatoid renal cell carcinoma: A rare paraneoplastic manifestation p. 81
Amit Gupta, Ashish Gupta, Sweety Gupta, Prashant Durgapal, Bina Ravi, Rohik Anjum T Sideek
DOI:10.4103/njs.NJS_4_19  
Renal cell carcinoma with sarcomatoid features is a rare presentation with a 5% incidence. Sarcomatoid renal cell carcinoma is usually associated with poor prognosis. It commonly metastasizes to the lungs, bones, and liver. Dermatological manifestation with paraneoplastic syndrome is extremely rare. Pathogenesis of PNP in renal cell carcinoma is not cleat; till date, however, few literature suggest antibodies against a group plakin family which plays a key role in intermediate filament attachment in RCC. We present PNP in a 64-year-old female associated with renal cell carcinoma.
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A modified laparoscopic technique for the removal of nonfragmentable giant gastric trichobezoar p. 84
Sakthivel Harikrishnan, Senthilkumar Perumal, Kanchan Sachanandani, M Thiruvarul, C Sugumar, Jeswanth Sathyanesan, P Ravichandran
DOI:10.4103/njs.NJS_20_19  
Bezoars are usually defined as collections of nondigestible matter that most commonly accumulates in the stomach and can sometimes extend to the small bowel. Trichobezoars are a rare entity which is most commonly observed in young psychiatric females with trichotillomania and trichophagia. Here, we report a case of giant gastric trichobezoar and a novel technique of laparoscopic removal in a 16 year old female with trichophagia. The giant gastric trichobezoar weighing about half a kilogram was removed en masse laparoscopically by a novel technique. She had an uneventful postoperative recovery and was discharged after psychiatric counseling.
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Resilient customized hollow vaginal stent for the treatment of vaginal agenesis in mayer–Rokitansky–Kuster–hauser syndrome p. 88
Manu Rathee, Savita Rani Singhal, Sanju Malik, Gunjan Gupta
DOI:10.4103/njs.NJS_43_18  
Vaginal agenesis is a common congenital anomaly in females and is most commonly associated with Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome. These patients can be treated with both surgical and nonsurgical procedures. Prefabricated as well as customized vaginal stents are used for the reconstruction and maintenance of neovagina. This case report explains the fabrication of customized tissue conditioner-reinforced acrylic vaginal stent for the treatment of a 20-year-old female having vaginal agenesis associated with MRKH syndrome. This vaginal stent with resilient surface provides a relatively easy, simple, and cost-effective alternative for the treatment of vaginal agenesis. It is also associated with increased compliance and comfort to the patient.
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Primary infertility secondary to posterior urethral valve p. 92
Timothy Uzoma Mbaeri, Chukwuemeka Okwudili Ezeama, Chinonso Odo
DOI:10.4103/njs.NJS_24_19  
A 34-year-old civil servant presented to our facility, following a referral from a gynecologist who was also seeing the wife. The man presented with a history of anejaculation and the inability to impregnate his wife after 23 months of marriage. History, physical examination, and ancillary investigation led to a diagnosis of primary infertility secondary to posterior urethral valve which was subsequently ablated. Three weeks after ablation, he started ejaculating, and 2 months later, the wife became pregnant.
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