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Arachnoid cysts are one of the benign spinal cystic lesions. Multiple nerve roots and spinal cord may be compressed by it, and operating is often recommended. Traditional surgical procedures often choose the posterior median approach, separating the paravertebral muscles, milling the lamina, fully exposing the cyst, partially or completely removing the cyst wall, looking for the leak, and then suturing and sealing. Here we present a case of giant spinal extradural arachnoid cyst in which a ultrafine flexible endoscope was used to visualize cystic spaces and identity the leaks. We repaired the leak after removing part of the cyst wall under the operating microscope, and the patient had an excellent recovery.

Objective: To evaluate the efficacy of subcutaneous etonogestrel implants for adenomyosis.Methods: We conducted a clinical observational study of 20 patients suffering from adenomyosis treated with subcutaneous etonogestrel implants from August 2015 to July 2017 and followed up for 36 months. We evaluated the efficacy of subcutaneous etonogestrel implants primarily based on the following indicators: the pictorial blood loss assessment chart (PBAC) for menstrual blood volume, changes in bleeding patterns, the visual analog scale (VAS) pain score for dysmenorrhea, uterine volume, serum cancer antigen 125 (CA125) levels, hemoglobin levels and side effects.Results: During the 3 years of follow-up, subcutaneous etonogestrel implants were removed from six patients, among whom one was diagnosed with endometrial cancer, four had an increased menstrual blood volume, and one entered menopause. In total, 14 patients were treated with subcutaneous etonogestrel implants for 3 years. Among these patients, the number of patients with heavy menstrual bleeding and high PBAC and VAS scores and serum CA125 levels was significantly decreased after implantation compared with that before implantation. In the eight patients with anemia, hemoglobin levels increased gradually. However, the uterine volumes did not significantly change. Bleeding patterns were changed but were tolerable.Conclusion: Subcutaneous etonogestrel implants represent a new option for the clinical treatment of adenomyosis for patients who refuse surgery.

OBJECTIVELaminoplasty has been used in recent years as an alternative approach to laminectomy for preventing spinal deformity after resection of intramedullary spinal cord tumors (IMSCTs). However, controversies exist with regard to its real role in maintaining postoperative spinal alignment. The purpose of this study was to examine the incidence of progressive spinal deformity in patients who underwent laminoplasty for resection of IMSCT and identify risk factors for progressive spinal deformity.METHODSData from IMSCT patients who had undergone laminoplasty at Beijing Tsinghua Changgung Hospital between January 2014 and December 2016 were retrospectively reviewed. Univariate tests and multivariate logistic regression analysis were used to assess the statistical relationship between postoperative spinal deformity and radiographic, clinical, and surgical variables.RESULTSOne hundred five patients (mean age 37.0 ± 14.5 years) met the criteria for inclusion in the study. Gross-total resection (> 95%) was obtained in 79 cases (75.2%). Twenty-seven (25.7%) of the 105 patients were found to have spinal deformity preoperatively, and 10 (9.5%) new cases of postoperative progressive deformity were detected. The mean duration of follow-up was 27.6 months (SD 14.5 months, median 26.3 months, range 6.2–40.7 months). At last follow-up, the median functional scores of the patients who did develop progressive spinal deformity were worse than those of the patients who did not (modified McCormick Scale: 3 vs 2, and p = 0.04). In the univariate analysis, age (p = 0.01), preoperative spinal deformity (p < 0.01), extent of tumor involvement (p < 0.01), extent of abnormal tumor signal (p = 0.02), and extent of laminoplasty (p < 0.01) were identified as factors associated with postoperative progressive spinal deformity. However, in subsequent multivariate logistic regression analysis, only age ≤ 25 years and preoperative spinal deformity emerged as independent risk factors (p < 0.05), increasing the odds of postoperative progressive deformity by 4.1- and 12.4-fold, respectively (p < 0.05).CONCLUSIONSProgressive spinal deformity was identified in 25.7% patients who had undergone laminoplasty for IMSCT resection and was related to decreased functional status. Younger age (≤ 25 years) and preoperative spinal deformity increased the risk of postoperative progressive spinal deformity. The risk of postoperative deformity warrants serious reconsideration of providing concurrent fusion during IMSCT resection or close follow-up after laminoplasty.

Objective To study on the clinical efficacy of precise localization of O-arm and navigation system in spinal cord lesions. Methods From Augst 2015 to September 2019, 22 patients with spinal cord lesions were arranged in the group.The intraoperative cross-sectional images were acquired by O-arm image system, which were transferred to the Stealth navigation system, and fused with pre-opreative MRI images. The image fusion was completed by the Medtronic Synergy Cranial software. The fused images were used to locate spinal cord lesions, assisted by the navigation system. The navigation errors were evaluated by measuring the maximum distance between the end of the lesion in MRI and its real position. Results The image fusion were completed in all patients, and we successfully completed the image-guided surgeries of the spinal cord lesions. The time of image processing was between 7 min and 19 min, and the mean value was 15.1 ± 2.2 min. The navigation error was between 0.9 mm and 5.3 mm, the mean value was 1.6 ± 0.9 mm. Conclusion The application of precise localization of O-arm and navigation system in spinal cord lesions is clinically reliable and feasible.

Schwannomas are the most common type of spinal tumor, and they most commonly occur in intradural extramedullary locations. Intramedullary schwannomas of the central nervous system are very rare and are difficult to diagnose using preoperative imaging. Here, we report a rare, tiny cervical intramedullary schwannoma and review the literature regarding the clinical presentation, magnetic resonance imaging, pathology, and surgical experience associated with this rare tumor type.

Spinal ependymomas (SEs) are common adult intramedullary tumors; however, determining the absolute boundary between the tumor and the tumor residual may be difficult.We assessed outcomes following the use of fluorescein sodium (FS) during surgical removal of SEs.We performed a retrospective analysis of 112 patients with SEs who were treated at Beijing Tsinghua Changgung Hospital between December 2014 and December 2016.Each patient received intravenous FS (3-4 mg/kg) to determine the SE boundaries during surgery.Tumor removal efficiencies and tumor residuals were assessed using magnetic resonance imaging (MRI) at 10 days and 3 months after surgical recovery; McCormick's spinal function classification was also performed at the 3-month follow-up.The complete tumor removal rate was 92%(103/112).Ninetyfour patients underwent tumor removal under fluorescent light, which provided distinctive tumor fluorescence.Tumor removal under white light was performed in 18 patients; fluorescent images were invisible or indistinctive in these 18 patients.At the 3-month follow-up, sensory function (85.8%(91/106)) and movement (84.3% (86/102)) were improved in patients with pre-surgical dysfunction; urination and defecation functions were improved in 66.7%(16/24).The McCormick spinal cord functional classifications, at the 3-month follow-up, showed significant differences in the percentages of patients with disease classified to each grade (Ⅰ-Ⅳ), compared with preoperative classifications (each, P < 0.05).There was no MRI evidence of tumor relapse or residuals at the 3-month follow-up.FS use during the surgical treatment of SE enables complete tumor removal and detection of tumor residuals.

This study explored the combined use of the O-arm and real-time navigation during spinal fixation. The clinical data for 60 patients undergoing spinal fixation, at Beijing Tsinghua Chang Gung Hospital between May 5, 2015 and May 1, 2017, were retrospectively analyzed. Pre-, intra-, and postoperative imaging findings were assessed. The patients were classified into the occipitocervical fusion (32 cases) and thoracic/lumbar/sacral spine fixation (28 cases, including 6 cases of percutaneous pedicle screw) groups. Lesion resections were performed microscopically. An O-arm, combined with real-time navigation, was used to assess spinal fixation. Efficacy was evaluated using operative times, X-ray times, screw positioning, and complications. Within the occipitocervical fusion group, 182 screws were placed in the cervical spine and 96 in the occipital bone. However, 6 screws penetrated the bone cortex and were adjacent to the vertebral arteries, based on O-arm three-dimensional imaging; therefore, the precision rate was 96.7%. Within the thoracic/lumbar/sacral spine fixation group, 148 pedicle screws were implanted, with 4 initially outside the vertebral body, yielding a precision rate of 97.3%. Ten percutaneous pedicle screws were implanted and well positioned. O-arm scans were performed 3 times/patient, with an average of 20-30 min/time. Screw implantation times were 5-7 min (cervical spine), 8-10 min (thoracic spine), and 6-8 min (lumbar spine). Intraoperative O-arm scans, combined with real-time navigation technology, allow real-time observation of screw angles and depths, improving the accuracy and safety of posterior screw fixations and reducing the radiation dose and frequency experienced by patients and surgeons.

Vasectomy is a simple, safe, effective, and economical method used worldwide for long-term male contraception. As a sur-gical operation, it has short-term and long-term complications such as hematoma formation, infection, sterilization failure, sperm granulomas, short-term postoperative pain (nodal pain, scrotal pain, and ejaculation pain), and chronic pain syn-drome. Whether it increases the risk of autoimmune disease, cardiovascular disease, testicular cancer, or prostate cancer is still controversial. Changes in plasma concentrations of luteinizing hormone, follicle-stimulating hormone, and testosterone after vasectomy have also been studied, as well as the relation between vasectomy and sexual function. Sperm quality de-creases very slowly after vasectomy, and vasovasostomy and intracytoplasmic sperm injection could help a couple achieve a pregnancy if they change their minds at any point. We include a follow-up strategy and suggestions for follow-up care at the end of this review.

Introduction: Premature ejaculation (PE) affects 8% to 30% of adult men worldwide. Recently, the incidence of PE is on the rise. A series of prior studies suggested that the incidence of PE is related to various biological factors as low testosterone, low serum vitamin D, diabetes, lower urinary tract symptoms, and other psychological factors. At present, the major treatments include selective serotonin reuptake inhibitors antidepressants (dapoxetine, paroxetine), topical anesthetics, phosphodiesterase-5 inhibitor, circumcision, and selective dorsal neurotomy (SDN). The previous study found that SDN is effective for PE. Methods and analysis: The electronic databases of MEDLINE, PubMed, Web of Science, EMBASE, Cochrane Library, Clinicaltrials. org, China National Knowledge Infrastructure Database (CNKI), Wan fang Database, China Biology Medicine Database (CBM), VIP Science Technology Periodical Database, Chinese Clinical Trial Registry will be retrieved. All the randomized controlled trials of selective dorsal penile neurotomy for patients with PE will be included. The outcome includes intravaginal ejaculation latency time and Chinese Index of Sexual Function for Premature Ejaculation-5. We will conduct this study strictly according to the Cochrane Handbook for Systematic Reviews of Interventions. Results: The present study is a protocol for systematic review and meta-analysis without results, and data analysis will be carried out after the protocol. We will share our findings on June 30th of 2021. Conclusion: SDN can effectively prolong IELT, but its efficacy has not been assessed scientifically and systematically. To address this limitation, this study will inspect the efficacy and safety of the SDN treatment in patients with PE. Ethics and dissemination: Formal ethical approval is not required in this protocol. We will collect and analyze data based on published studies, and since there are no patients involved in this study, individual privacy will not be under concerns. The results of this review will be disseminated to peer-reviewed journals or submit to related conferences. Protocol registration number: INPLASY202070084

This study aimed to evaluate the accuracy of screw placement and clinical outcomes in patients undergoing occipitocervical fusion.Patients who underwent occipitocervical fusion with O-arm-based navigation were retrospectively reviewed between January 2015 and December 2017. The patients' characteristics, clinical and radiographic outcomes, and surgical complications were recorded and analyzed. Cervical screw insertion accuracy was evaluated using the Richter scale.Thirty consecutive patients (11 male and 19 female) with an average treatment age of 40.03 ± 15.19 years were studied. The most common cause was atlantoaxial instability combined with Chiari malformation (63.33%). Weakness (76.67%) and paresthesia (70.00%) were the most common symptoms. Eighty-six occipital and 139 cervical screws were placed using an O-arm-assisted navigation system. In total, 130 (93.53%) cervical screws were graded as group A and 9 (6.47%) as group B. The optimal accuracy rate was 88.41% (61 of 69 screws) in the first 15 patients and 98.57% (69 of 70 screws) in the subsequent 15 patients. The mean follow-up time was 7.50 ± 5.70 months. The mean Japanese Orthopedic Association scores were 13.30 ± 2.41 preoperatively and 15.30 ± 1.60 at final follow-up (P0.001), and the mean recovery rate in the Japanese Orthopedic Association score was 53.26 ± 33.82%. Clinical improvement was seen in 25 patients (83.33%), whereas no change was observed in 5 patients (16.67%). The overall complication rate was 6.67% (2/30), with 1 intraoperative vertebral artery injury and 1 postoperative screw loosening.Occipitocervical fusion with O-arm-based navigation is effective and safe for treating instability of the craniovertebral junction. Intraoperative navigation can help surgeons insert screws accurately.

Objective We sought to study the application of precise intraoperative localization of small intramedullary spinal cord tumors. Methods From November 2015 to August 2017, 5 patients with small intramedullary spinal cord tumors were arranged in this group. By using the O-arm image system, we acquired the intraoperative computed tomography images of all patients and sent them to the Stealth navigation system. Medtronic Synergy Cranial software was used to complete the image fusion with preoperative magnetic resonance images, and the fused images were used to localize the intramedullary spinal cord tumors by the navigation system. The navigation errors were evaluated by measuring the maximum distance between the end of the tumor in sagittal magnetic resonance imaging and its real position. Results Five patients accomplished the multimodal image fusion, and we successfully completed the image-guided surgeries. The mean diameter of tumors was 12.2 ± 3.1 mm in sagittal magnetic resonance imaging, and the mean incision length was 12.7 ± 3.3 mm. The time of image processing was between 13 minutes and 17 minutes, and the mean value was 15 ± 1.6 minutes. The navigation error was between 0.9 mm and 1.5 mm, and the mean value was 1.2 ± 0.2 mm. Conclusions The application of the multimodal image fusion combined with intraoperative O-arm image navigation system can be used to localize small intramedullary tumors.

Objectives: To describe the efficiency, blood loss, operating time and mean hospital stay of enucleation of a large myoma by ‘simultaneous morcellation in situ’ (SMI) in laparoscopic myomectomy (LM). Patients and Methods: Twenty-six patients with leiomyomas >9 cm in diameter were treated using LM and SMI from January 2006 to December 2009. Patient characteristics and operative data were collected and analyzed. Results: The average operating time was 106.4 ± 38.5 min (range 50–175 min). The average blood loss was 278.2 ± 164.6 ml (range 50–800 ml). There was no other complication, and no patient underwent conversion to laparotomy. The average postoperative hospital stay was 5.4 ± 0.2 days (range 5–7 days). Conclusion: Our study confirmed that SMI is an efficient and safe way to remove large uterine myomas (>9 cm) during LM.

Endometrial stromal sarcoma (ESS) is a rare malignant tumor of the uterus. The standard treatment is surgery, such as total hysterectomy with bilateral salpingo-oophorectomy. The use of adjuvant treatment, including chemotherapy, radiation therapy and endocrine therapy, remains controversial, so it is uncommon for conservative management to be performed in patients with low-grade ESS. The present study reports the case of a 19-year-old female with ESS at stage III who underwent a local mass resection by laparoscopic surgery. A high dose of progestin (medroxyprogesterone acetate) therapy was then administered. Conservative management resulted in complete remission of the low-grade ESS, with no sign of recurrence at the 33-month follow-up.

IntroductionAggressive Angiomyxoma (AAM) is a rare soft tissue neoplasmwhich predominantly occurs at the female pelvic peritoneum andperineum region, with female-to-male ratio is 6.6:1(Chan et al.,2000). AAM is characterized as non-encapsulated and slow-growingbenign tumor. However, their locally invasive and recurrent natureoften leads to difficulties in clinical treatment. On the other side,misdiagnosis is also a problem because of their no-special clinicalrepresentations. So far, 310 papers were retrieved in Pubmed usingsearch key word “Aggressive Angiomyxoma”. However, most of thesepapers are case report because of their rarity, which is also responsibleforthedeficiencyofdiagnosisandtreatmentexperienceofthisdisease.In this paper, we present a case of small-sized AAM complicating withmassive ascites which has not been reported before. We hope that theclinical procedure of this case would offer more useful informationson this disease.Case reportA30 years-oldwomanwastransferredtoourunitfromdepartmentof gastroenterology for unexplainable massiveascites. The patient'sab-domen circumference and bodyweight have been increasing graduallyin the past 2 years. She has been admitted to department of gastroen-terology in our hospital followed by detailed systemic examination in-cluding CT scanning. However, the source of ascites was not found. Solaparoscopic exploration surgery was recommended. The patient had