Periurethral Suspension Stitch During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of the Technique and Continence Outcomes

Background: Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome. Objective: We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence. Design, setting, and participants: We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2). Surgical procedure: The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CTI needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied. Measurements: Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC] at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine. Results and limitations: In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk: 95% confidence interval [CI]: 6.387-8.288) compared to the non-suspension group (median: 7 wk; mean: 9.585 wk: 95% CI: 7.558-11.612; log rank test, p = 0.02). Conclusions: The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure. (C) 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Obesity Decreases Time to Claudication and Delays Post-Exercise Hemodynamic Recovery in Elderly Peripheral Arterial Disease Patients

Background: Although obesity is usually observed in peripheral arterial disease (PAD) patients, the effects of the association between these diseases on walking capacity are not well documented. Objective: The main objectives of this study were to determine the effects of obesity on exercise tolerance and post-exercise hemodynamic recovery in elderly PAD patients. Methods: 46 patients with stable symptoms of intermittent claudication were classified according to their body mass index (BMI) into normal group (NOR) = BMI < 28.0 and obese or in risk of obesity group (OBE) = BMI >= 28.0. All patients performed a progressive graded treadmill test. During exercise, ventilatory responses were evaluated and pre- and post-exercise ankle and arm blood pressures were measured. Results: Exercise tolerance and oxygen consumption at total walking time were similar between OBE and NOR. However, OBE showed a lower claudication time (309 +/- 151 vs. 459 +/- 272 s, p = 0.02) with a similar oxygen consumption at this time. In addition, OBE presented a longer time for ankle brachial index recovery after exercise (7.8 +/- 2.8 vs. 6.3 +/- 2.6 min, p = 0.02). Conclusion: Obesity in elderly PAD patients decreased time to claudication, and delayed post-exercise hemodynamic recovery. These results suggest that muscle metabolic demand, and not total workload, is responsible for the start of the claudication and maximal exercise tolerance in PAD patients. Moreover, claudication duration might be responsible for the time needed to a complete hemodynamic recovery after exercise. Copyright (c) 2008 S. Karger AG, Basel

Rate of occupational leg swelling is greater in the morning than in the afternoon

The aim of this study was to investigate the rate of occupational leg swelling depending on the time period of the working day Volumetric variations of the legs of 70 hospital employees, enrolled in three groups, were evaluated. Group I: 35 morning shift workers; Group II: 35 afternoon shift workers; and Group III: 15 individuals randomly selected from Groups I and II, who were evaluated on the day they worked 12 hours consecutively. Volumetry was performed before and after each shift for both legs of the participants in Groups I and II. For Group III volumetry was performed early in the morning, at noon and in the evening, For statistical analysis, the Student`s t-test and Mann-Whitney test were used with an alpha error of 5%. being considered acceptable (P value < 0.05). Significant increases in volume were recorded for the limbs in all three groups (P value < 0.001). On comparing Groups I and II, the accumulation of fluids was significantly higher in the morning than in the afternoon (P value < 0.003). Asymptomatic workers may present with oedema of the legs during their work with the rate of oedema being different for morning and afternoon shifts. The possibility of wearing compression stockings should be considered for this type of work.

Elevation of Uterine Basal Tone and Fetal Heart Rate Abnormalities After Labor Analgesia A Randomized Controlled Trial

OBJECTIVE: To estimate the effects of combined spinal-epidural and traditional epidural analgesia on uterine basal tone and its association with the occurrence of fetal heart rate (FHR) abnormalities. METHODS: Seventy-seven laboring patients who requested pain relief during labor were randomly assigned to combined spinal-epidural (n=41) or epidural analgesia (n=36). Uterine contractions and FHR were recorded 15 minutes before and after analgesia. Uterine tone was evaluated with intrauterine pressure catheter. Primary outcomes were the elevation of baseline uterine tone and occurrence of FHR prolonged decelerations or bradycardia after analgesia. The influence of other variables such as oxytocin use, hypotension, and speed of pain relief were estimated using a logistic regression model. RESULTS: The incidence of all outcomes was significantly greater in the combined spinal-epidural group compared with epidural: uterine hypertonus (17 compared with 6; P=.018), FHR abnormalities (13 compared with 2; P<.01), and both events simultaneously (11 compared with 1; P<.01). Logistic regression analysis showed the type of analgesia as the only independent predictor of uterine hypertonus (odds ratio 3.526, 95% confidence interval 1.21-10.36; P=.022). For the occurrence of FHR abnormalities, elevation of uterine tone was the independent predictor (odds ratio 18.624, 95% confidence interval 4.46-77.72; P<.001). Regression analysis also found a correlation between decrease on pain scores immediately after analgesia and the estimated probability of occurrence of hypertonus and FHR abnormalities. CONCLUSION: Combined spinal-epidural analgesia is associated with a significantly greater incidence of FHR abnormalities related to uterine hypertonus compared with epidural analgesia. The faster the pain relief after analgesia, the higher the probability of uterine hypertonus and FHR changes. CLINICAL TRIAL REGISTRATION: Umin Clinical Trials Registry, http://www.umin.ac.jp/ctr/index.htm, UMIN000001186

One-stage laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 for bilateral colorectal liver metastases

Bisegmentectomy 7-8 is feasible even in the absence of a large inferior right hepatic vein. To our knowledge, this operation has never been performed by laparoscopy. This study was designed to present video of pure laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 in one-stage operation for bilateral liver metastasis. A 67-year-old man with metachronous bilobar colorectal liver metastasis was referred for surgical treatment after neoadjuvant chemotherapy. CT scan disclosed two liver metastases: one located between segments 7 and 8 and another one in segment 2. At liver examination, another metastasis was found on segment 3. We decided to perform a bisegmentectomy 7-8 along with bisegmentectomy 2-3 in a single procedure. The operation began with mobilization of the right liver with complete dissection of retrohepatic vena cava. Inferior right hepatic vein was absent. Right hepatic vein was dissected and encircled. Upper part of right liver, containing segment 7 and 8, was marked with cautery. Selective hemi-Pringle maneuver was performed and right hepatic vein was divided with stapler. At this point, liver rotation to the left allowed direct view and access to the superior aspect of the right liver. Liver transection was accomplished with harmonic scalpel and endoscopic stapling device. Bisegmentectomy 2-3 was performed using the intrahepatic Glissonian approach. The specimens were extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks. Operative time was 240 minutes with no need for transfusion. Recovery was uneventful. Patient was discharged on the fifth postoperative day. Patient is well with no evidence of disease 14 months after liver resection. Tumor markers are within normal range. Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions. This operation can be performed safely by laparoscopy. Preservation of segments 5 and 6 permitted simultaneous resection of segments 2 and 3 with adequate liver remnant.

Can an adequate energy intake be able to reverse the negative nitrogen balance in mechanically ventilated critically ill patients?

Purpose: Adequate energy provision and nitrogen losses prevention of critically ill patients are essentials for treatment and recovery. The aims of this study were to evaluate energy expenditure (EE) and nitrogen balance (NB) of critically ill patients, to classify adequacy of energy intake (El), and to verify adequacy of El capacity to reverse the negative NB. Methods: Seventeen patients from an intensive care unit were evaluated within a 24-hour period. Indirect calorimetry was performed to calculate patient`s EE and Kjeldhal for urinary nitrogen analysis. The total El and protein intake were calculated from the standard parenteral and enteral nutrition infused. Underfeeding was characterized as El 90% or less and overfeeding as 110% or greater of EE. The adequacy of the El (El EE(-1) x 100) and the NB were estimated and associated with each other by Spearman coefficient. Results: The mean EE was 1515 +/- 268 kcal d(-1) and most of the patients (11/14) presented a negative NB (-8.2 +/- 4.7 g.d(-1)). A high rate (53%) of inadequate energy intake was found, and a positive correlation between El EE(-1) and NB was observed (r = 0.670; P = .007). Conclusion: The results show a high rate of inadequate El and negative NB, and equilibrium between El and EE may improve NB. Indirect calorimetry can be used to adjust the energy requirements in the critically ill patients. (C) 2010 Elsevier Inc. All rights reserved.

Effectiveness of iron repletion in the diet for the optic nerve development of anaemic rats

Purpose To compare the process of myelination in the developing optic nerve (ON) of anaemic rats with the subsequent recovery after being fed an iron-recovery diet. Methods In this study, the morphometrical parameters in the ON were assessed by electron microscopy in Wistar rats that were on an iron-deficient diet for 32 days or for 21 days followed by 10 days on an iron-recovery diet. Qualitative and quantitative analyses were performed using representative electron ultramicrographs. Data were analysed by one-way analysis of variance (ANOVA). When differences were detected, comparisons were made using Tukey`s post hoc test (P<0.05 was considered to be significant). Results Qualitative analysis of the ONs in anaemic and recovered animals showed a higher rate of deformed axons and increased lamellar separation in the myelin sheath when compared with the respective control group. The ON of the anaemic group showed a reduced mean density of myelinated fibres when compared with the control group. The fibre area ratio, axon area ratio, and myelin area ratio of large axons/small axons in the ONs of the control group showed the highest values for the myelin areas, axon areas, and total fibre areas. The control group showed a significantly higher myelin sheath thickness when compared with the anaemic and recovered groups. Conclusions Our data indicate that iron is necessary for maintenance of the ON cell structure, and that morphological damage from iron deficiency is not easily reverted by iron repletion. Eye (2010) 24, 901-908; doi:10.1038/eye.2009.205; published online 14 August 2009

Importance of psychological intervention for the recovery of children submitted to elective surgery

Purpose: The effects of anxiety on the patient and his/her family are known to be the main factors that influence health recovery in child surgery. When the whole family can be prepared and supported by psychologic intervention, the damage to child behavior and family anxiety is attenuated. Methods: This study was conducted in children between 2 and 6 years old, divided into 2 groups of 10 pairs each. The experimental group received psychologic intervention, whereas the control group did not. One month after the surgery, they were reevaluated and compared with the same instruments used in the beginning of the study. The instruments used were as follows: the State-Trait Anxiety Inventory with the mothers and the Rutter`s Child Behavior A2 Scale and the Posthospital Behavior Questionnaire with the children. Results: The results were compared by the Wilcoxon and Mann-Whitney nonparametric tests for independent samples, both at the P <.05 significance levels. Mothers stated that anxiety was different in the postsurgery period, showing a significant decrease when comparing the experimental and control groups. Both instruments to measure child behavior also showed that prepared children had less habit changes than the control group, which showed increased levels of inadequate behavior. Conclusions: These data confirm reports in literature regarding child preparation before medical intervention and reinforces the importance of specialized presurgery planning procedures by the proper professional interfaced with the surgical colleagues, all aiming toward the best recovery for the children. (C) 2009 Elsevier Inc. All rights reserved.

Glutamine supplementation does not improve protein synthesis rate by the jejunal mucosa of the malnourished rat

It has been demonstrated that glutamine, a conditionally essential amino acid, improves nitrogen balance, acts as a stimulant of protein synthesis, and decreases proteolysis in myopathic children. In contrast, other studies have shown no beneficial effect of glutamine supplementation on burn victims or critically ill patients. Nonetheless, we hypothesized that glutamine supplementation would increase the fractional protein synthesis rate (FSR) in the jejunal mucosa of malnourished male Wistar rats. Thus, the objective of the present study was to test the effect of daily oral glutamine supplementation (0.42 g kg(-1) d(-1) for 14 days) on the FSR of the jejunal mucosa of healthy and malnourished rats. A 4-hour kinetic study with L-[1-(13)C]leucine was subsequently performed, and jejunal biopsies were obtained 1.5 cm from the Treitz angle and analyzed. Malnourished rats showed a 25% weight loss and increased urinary nitrogen excretion. Plasma amino acid concentration did not differ between groups. (13)C enrichment in plasma and jejunal cells was higher in the malnourished groups than in the healthy group. The FSR (percent per hour) was similar for the control and experimental groups (P > .05), with a mean range of 220%/h to 27%/h. Oral glutamine supplementation alone did not induce higher protein incorporation by the jejunal mucosa in malnourished rats, regardless of total food intake or the presence or absence of glutamine supplementation. (C) 2009 Elsevier Inc. All rights reserved.

Influence of Glomerular Filtration Rate on the Pharmacokinetics of Cyclophosphamide Enantiomers in Patients With Lupus Nephritis

The pharmacokinetics of cyclophosphamide (CYC) enantiomers were evaluated in patients with lupus nephritis distributed in 2 groups according to creatinine clearance: group 1 (90.6-144.6 mL/min/1.73 m(2)) and group 2 (42.8-76.4 mL/min/ 1.73 m(2)). All patients were treated with 0.75 to 1.3 g of racemic CYC as a 2-hour infusion and with 1 mg intravenous midazolam as a drug-metabolizing marker. CYC enantiomers and midazolam concentrations in plasma were measured by liquid chromatography/tandem mass spectrometry (LC/MS/MS). The following differences (Wilcoxon test, P <= .05) were observed between the (S)-(-) and (R)-(+) enantiomers: AUC(0-infinity) 152.41 vs 129.25 mu g.h/mL, CL 3.28 vs 3.89 L/h, Vd 31.38 vs 29.74 L, and t(1/2) 6.79 vs 5.56 h for group 1 and AUC(0-infinity) 167.20 vs 139.08 mu g.h/mL, CL 2.99 vs 3.59 L/h, and t(1/2) 6.15 vs 4.99 h for group 2. No differences (Mann test, P <= .05) were observed between groups 1 and 2 in the pharmacokinetic parameters of both enantiomers. No significant relationship was observed between midazolam clearance (2.92-16.40 mL/min.kg) and clearance of each CYC enantiomer. In conclusion, CYC kinetic disposition is enantioselective, resulting in higher exposures of the (S)-(-) enantiomer in lupus nephritis patients, and the pharmacokinetic parameters of both enantiomers are not altered by the worsening of renal condition.

3.0-T MRI evaluation of patients with chronic liver diseases: initial observations

Purpose: To describe the use of 3.0-T magnetic resonance imaging (MRI) for the evaluation of chronic liver diseases. Materials and Methods: Two groups of patients who had chronic liver diseases and underwent 3.0-T MRI for evaluation of the liver were included in the study. The first group of patients included 66 consecutive patients (33 male, 33 female; mean age +/- standard deviation, 56 +/- 11). The second group of patients included 30 consecutive patients (18 males, 12 females; mean age +/- standard deviation, 53 +/- 10) in whom Variable-Rate Selective Excitation (VERSE) pulses and improved adjustments procedure were used during the acquisitions. Imaging findings of chronic liver diseases, predetermined artifacts and image quality of all individual sequences in the first group and predetermined artifacts and image quality of T2-weighted sequences in the second group were reviewed retrospectively and independently by two reviewers. chi-Square tests were used to compare the findings between two groups of patients and individual sequences. Kappa statistics were used to determine the extent of agreement between the reviewers. Results: Fifteen dysplastic nodules in 6 of 66 (9%) patients and 12 hepatocellular carcinomas in 11 of 66 (17%) patients were detected. Excluding motion artifacts, three-dimensional (313) T1-weighted gradient-echo (GE) sequence was the least affected sequence by the artifacts. Image quality of T1-weighted 3D-GE sequences was excellent in 43 of 66 (65%) patients. In-phase and out-of-phase T1-weighted spoiled GE (SGE) images were fair in 62 of 66 (94%) and 61 of 66 (92%) patients, respectively. The image quality of short tau inversion recovery (STIR) and half-Fourier rapid acquisition with relaxation enhancement (RARE) sequences were fair in 31 of 66 (47%) and 53 of 66 (80%) patients. STIR and half-Fourier RARE sequences in the second group demonstrated significantly better image quality (P=.03 and P<.0001). Conclusion: 3.0-T MRI allows the acquisition of very high quality postgadolinium 3D-GE sequence, which permitted the detection and characterization of lesions in the setting of chronic liver diseases. The use of VERSE pulses and improved adjustments procedure improved the image quality of T2-weighted sequences. In-phase/out-of-phase SGE sequences are at present of fair quality. (C) 2008 Elsevier Inc. All rights reserved.