Radical Retropubic Prostatectomy for Localized Prostate Cancer in Renal Transplant Patients

OBJECTIVE To investigate the feasibility of radical retropubic prostatectomy (RRP) in renal transplant recipients with clinically localized prostate cancer. METHODS A prospective protocol was established between August 2004 and November 2007. In that period, 8 patients diagnosed with localized prostate cancer were submitted to RRP, and their clinicopathologic data were reviewed. RESULTS The mean age (standard deviation) at surgery was 59.6 +/- 6.7 years (range, 49-67 years). All patients had TIC tumors, except for 1 with a T2A tumor. The mean preoperative prostate-specific antigen value was 4.5 +/- 1.8 ng/mL (range, 1.6-7.0 ng/mL). The mean interval between renal transplantation and RRP was 89.9 +/- 65.1 months (range, 40-209 months). The procedure was well tolerated without major complications, and all patients were discharged on the fifth postoperative day. There was no impairment to bladder descent caused by the presence of the allograft or the ureteroneocystostomy. Urethrovesical anastomosis was easily performed in all cases in the standard manner. Blood transfusion was needed in 2 patients (1 received 2 U and another 5 U of blood). The mean operative duration was 183 +/- 29.7minutes (range, 150-240 minutes), the mean estimated blood loss was 656 +/- 576 mL (range, 100-2000 mL), and no deterioration of graft function was observed. All patients were followed, and the mean follow-up was 10.5 months (range, 2-30 months). Prostate-specific antigen was undetectable in all cases during this time frame. CONCLUSIONS Radical retropubic prostatectomy in renal transplant patients is safe, effective, and can be easily performed in the same manner as described by Walsh, regardless of the presence of the allograft. The only necessary technical modification is the avoidance of ipsilateral lymphadenectomy to prevent damage to the transplanted organ. UROLOGY 72: 1362-1365, 2008. (C) 2008 Elsevier Inc.

Penile erection induced in vivo by a purified toxin from the Brazilian spider Phoneutria nigriventer

OBJECTIVES To verify the effect on erectile tissue of mice of two neuropeptides extracted from the poison of a spider, Phoneutric nigriventer, (Tx2-5 and -6. termed `eretina`) after direct injection into the corpus cavernosum, to assess the minimum dosage necessary for effect. the time for initiation of action, the local duration of the erection, histological effects and the presence of local and systemic side-effects. MATERIALS AND METHODS When applied intraperitoneally, eretina promotes the relaxation of cavernous smooth muscle, thus causing penile erection. Thirty-five mice were divided in two groups; 10 control mice were injected 20 mu L of saline solution, and in the treated group, 25 mice were divided into groups of five and each subgroup received eretina in decreasing doses (0.024, 0.012, 0.006, 0.003 and 0.0015 mu g/kg) until the minimum dose that produced an erection was determined. After treatment 211 mice were monitored to determine the response and any collateral effects. RESULTS The minimum dose producing an erection was 0.006 mu g/kg, the five mice in this group having evidence of an erection at 35-45 min after injection. The histology of the cavernosum of mice treated with eretina showed dilatation and congestion of the vascular spaces with more blood than in controls. With the minimum dose there were no local or systemic collateral effects and the erection was lost after 120-140 min. CONCLUSION The minimum dose of eretina producing an erection in mice was determined. and the agent was safe for this use as it did not produce any collateral toxic effects. These studies indicate a possible means of determining the mechanism of action of eretina.

Management of Common Bile Duct Stones in Cirrhotic Patients with Coagulopathy: A Comparison of Supra-Papillary Puncture and Standard Cannulation Technique

Bleeding is not uncommon following endoscopic sphincterotomy. Supra-papillary puncture (SPP) might be safer than standard cannulation (SC) techniques in patients with coagulopathy. The aim of the study was to compare the safety and effectiveness of SPP and SC. This was a prospective case control intervention study. Decompensated cirrhotic patients with coagulopathy and choledocolithiasis underwent SC and SPP methods for biliary access. One hundred five patients (56 [53.3%] men, mean [SD] age 56 [15.8]) underwent ERCP. SC and SPP were performed in 63 and 42 patients, respectively. Biliary access was achieved in 56/63 (89%) and 40/42 (95%) of patients undergoing SC and SPP, respectively (P = 0.13; 95% CI [-0.16; 0.03]). Complications occurred in 10/63 (15.8%) patients undergoing SC and 5/42 (11.9%) SPP (P = 0.28; 95% CI [-0.17, 0.16]). Five (7.9%) and two (3.2%) episodes of post-sphincterotomy bleeding was seen in the SC and SPP groups, respectively (P = 0.36; 95% CI [-0.16, 0.05]). In contrast, three (4.8%) episodes of pancreatitis were seen in the SC and none in the SPP group (P = 0.05; 95% CI [0.001; 0.004]). A cost-effectiveness analysis demonstrated that SPP is an acceptable alternative at an ICER of US$ 5,974.92 per additional successful procedure. SPP is a safe and effective technique for the management of common bile duct stones in decompensated cirrhotic patients. Conditional to the willingness-to-pay and to the local ERCP-related costs, SPP is also a cost-effective alternative to the SC methods. SPP is associated with a lower rate of complications but larger studies to validate these findings are necessary.

Percutaneous ultrasound-guided renal biopsy in children - safety, efficacy, indications and renal pathology findings: 14-year Brazilian university hospital

Introduction: Pediatric percutaneous renal biopsy (Bx) is a routine procedure in pediatric nephrology to obtain renal tissues for histological study. We evaluated the safety, efficacy, indications and renal findings of this procedure at a tertiary care pediatric university hospital and compared our findings with the literature. Methods: Retrospective study based on medical records from January 1993 to June 2006. Results: In the study period, 305 Bx were performed in 262 patients, 127 (48.5%) male, aged 9.8 +/- 4.2 years. A 16-gauge needle was utilized in 56/305 Bx, an 18-gauge needle in 252/305 Bx (82.6%). 56.1% Bx were performed under sedation plus local anesthesia, 43.9% under general anesthesia. The number of punctures per Bx was 3.1 +/- 1.3. Minor complications occurred in 8.6% procedures. The 16-gauge needle caused a higher frequency of renal hematomas (p = 0.05). The number of glomeruli per puncture was >= 5 in 96.7% and >= 7 in 92%. Glomeruli number per puncture and frequency of complications were not different according to the type of anesthesia used. A renal pathology diagnosis was achieved in 93.1% Bx. The main indications of Bx were nephrotic syndrome (NS), lupus nephritis (LN) and hematuria (HE). The diagnosis of minimal change disease (MCD) (61.3%), class V (35.6%) and IgA nephropathy (26.3%) predominated in NS, LN and HE patients, respectively. Conclusion: Pediatric real-time ultrasound-guided percutaneous renal biopsy was safe and effective. The main clinical indications for Bx were NS and LN, the predominant renal pathology diagnoses were MCD and class V LN.

Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate

Objectives (1) Study the effectiveness of intravariceal injection of n-butyl-2-cyanoacrylate to treat acute gastric variceal (GV) bleeding and (2) study the impact of the type of GV and hepatic function on endoscopic hemostasis and mortality outcomes. Methods Fourty-eight patients with acute GV bleeding underwent intravariceal injection of n-butyl-2-cyanoacrylate and were followed until death or study conclusion (12-52 months). Results Primary hemostasis (no re-bleeding within 48 h) was accomplished in 42 patients (87.5%). Appearance of the bleeding site at the time of initial endoscopy, grade of cirrhosis and location of GV were not significant predictors of immediate hemostasis. Early re-bleeding (48 h to 6 weeks) occurred in 20.5% of patients and late re-bleeding (beyond 6 weeks) in 20.5% of patients. While the Child-Pugh score was predictive of re-bleeding and mortality, the type of GV and stigmata at initial endoscopy were not significant predictors of re-bleeding and mortality. Over a mean follow-up of 18 months, mortality rates were 43.9% and bleeding was the commonest cause of death. Conclusion Endoscopic injection of n-butyl-2-cyanoacrylate is effective and safe for treating bleeding GV. Patients with poor hepatic function are at higher risk of re-bleeding and death after acute gastric variceal bleed.

Comparison of renal transplantation outcomes in children with and without bladder dysfunction. A customized approach equals the difference

Purpose: We examined the development of urological abnormalities in a group of pediatric renal transplant recipients. Materials and Methods: We reviewed 211 patients younger than 19 years who underwent 226 renal transplants. Three groups of patients were studied-136 children with end stage renal disease due to a nonurological cause (group 1), 56 children with a urological disorder but with an adequate bladder (group 2a) and 19 children with lower urinary tract dysfunction and/or inadequate bladder drainage (group 2b). A total of 15 children in group 2b underwent bladder augmentation (ureterocystoplasty in 6, enterocystoplasty in 9), 2 underwent continent urinary diversion, 1 underwent autoaugmentation and 1 underwent a Mitrofanoff procedure at the bladder for easier drainage. Kidney transplantation was performed in the classic manner by extraperitoneal access, and whenever possible the ureter was reimplanted using an antireflux procedure. Results: At a mean followup of 75 months 13 children had died, 59 grafts were lost and 15 children had received a second transplant. Two patients in group 2a required a complementary urological procedure to preserve renal function (1 enterocystoplasty, 1 vesicostomy). A total of 12 major surgical complications occurred in 226 kidney transplants (5.3%), with a similar incidence in all groups. The overall graft survival at 5 years was 75%, 74% and 84%, respectively, in groups 1, 2a and 2b. Conclusions: With individualized treatment children with severely inferior lower urinary tract function may undergo renal transplantation with a safe and adequate outcome.

Small Bowel Endoscopy Using the Double-Balloon Technique: Four-Year Results in a Tertiary Referral Hospital in Brazil

Background: Double-balloon enteroscopy (DBE) allows evaluation and therapy for various small bowel diseases. In this series the outcome of a 4-year experience in a tertiary hospital school in Brazil is reported. Methods: A total of 457 consecutive DBE were performed in 418 patients from August 2004 to August 2008. 93 patients with several indications, whose aim was not the evaluation of suspected diseases of the small bowel mucosa, were excluded, therefore leaving 364 DBE in 325 patients for analysis. Data were retrospectively collected with regard to clinical, endoscopic findings, therapy and complications. Results: Among the 364 DBE performed in 325 patients, 143/325 were males (44%) and 182/325 females (56%) with a mean age of 48.6 +/- 15.7 years (range 17-89). Mean investigation time was 64 +/- 22 min (range 35-135). The depth of insertion beyond the ligament of Treitz was 230 +/- 85 cm (range 30-500) by the antegrade approach and 140 +/- 75 cm (range 0-320) by the retrograde approach. Total enteroscopy was achieved in 41.66% of the attempts (30 of 72 patients). Overall diagnostic yield was 54.95% (200 of 364 procedures) ranging from 0 to 100% in this series, depending on the indication. Angiodysplasia was the main diagnosis in 24.5% (49 of 200 procedures) and endoscopic treatment, including biopsies, hemostasis, tattooing and polypectomy were performed in 65.38% (238 of 364 procedures). No major complications were reported. Conclusions: DBE is a feasible, safe and well-tolerated procedure allowing endoscopic therapy. Selection of indications increases its diagnostic yield. Copyright (C) 2009 S. Karger AG, Basel

Enterohormonal changes after digestive adaptation: Five-year results of a surgical proposal to treat obesity and associated diseases

Background Recent physiological knowledge allows the design of bariatric procedures that aim at neuroendocrine changes instead of at restriction and malabsorption. Digestive adaptation is a surgical technique for obesity based in this rationale. Methods The technique includes a sleeve gastrectomy, an omentectomy and a jejunectomy that leaves initial jejunum and small bowel totaling at least 3 m (still within normal variation of adult human bowel length). Fasting ghrelin and resistin and fasting and postprandial GLP-1 and PYY were measured pre- and postoperatively. Results Patients: 228 patients with initial body mass index (BMI) varying from 35 to 51 kg/m(2); follow-up: I to 5 years; average EBMIL% was 79.7% in the first year; 77.7% in the second year; 71.6% in the third year; 68.9% in the fourth year. Patients present early satiety and major improvement in presurgical comorbidities, especially diabetes. Fasting ghrelin and resistin were significantly reduced (P<0.05); GLP-1 and PYY response to food ingestion was enhanced (P<0.05). Surgical complications (4.4%) were resolved without sequela and without mortality. There was neither diarrhea nor detected malabsorption. Conclusions Based on physiological and supported by evolutionary data, this procedure creates a proportionally reduced gastrointestinal (GI) tract that amplifies postprandial neuroendocrine responses. It leaves basic GI functions unharmed. It reduces production of ghrelin and resistin and takes more nutrients to be absorbed distally enhancing GLP-1 and PYY secretion. Diabetes was improved significantly without duodenal exclusion. The patients do not present symptoms nor need nutritional support or drug medication because of the procedure, which is safe to perform.

Comparison of Full Versus Short Induced-Sleep Polysomnography for the Diagnosis of Sleep Apnea

Objectives/Hypothesis: Polysomnography (PSG) is the gold-standard method for diagnosing obstructive sleep apnea (OSA). However, the gap between demand and capacity in performing PSG is a major health-care problem. We sought to validate a short day-time induced sleep for the diagnosis of OSA. Study Design: Prospective diagnostic method validation. Methods: We studied 25 consecutive patients referred to the sleep laboratory and 15 healthy volunteers. All subjects were evaluated by means of full overnight PSG (Full-PSG) and short day-time induced-sleep PSG (Induced-PSG). Sleep was monitored during both procedures (Embla, 16 channels). Sleep was induced by slow intravenous drip infusion of midazolam. Results: The population studied (N = 40) was 60% male (mean age, 42 +/- 10 years; body mass index, 29 +/- 6.5 kg/m(2)). Sleep was successfully induced in all subjects, and no complications were observed (midazolam doses, 6.2 +/- 3.8 mg; time of induced sleep 41.5 +/- 18.9 minutes). The apnea-hypopnea index (AHI) and minimal oxygen saturation during Full-PSG versus Induced-PSG were similar: median AHI (with 25%-75% interquartile range) was 13 (3-35) events per hour versus 17 (4-36) events per hour, and median oxygen saturation was 84% (75-90) versus 85% (76-92); P = .89 and P = .53, respectively. The majority of the respiratory events during induced sleep were obstructive and similar to those observed during Full-PSG. AHI and lowest oxygen saturation during Induced-PSG correlated significantly with Full-PSG (r = 0.67 and r = 0.77, respectively). Sensitivity and specificity for the diagnosis of OSA (AHI > 15 events per hour) by Induced-PSG were 0.83 and 0.72, respectively. Conclusions: Induced-PSG by midazolam during the day is safe and correlates with Full-PSG; it therefore is a promising alternative method in the diagnosis of OSA.

The role of videopericardioscopy in evaluating indeterminate pericardial effusions

Background. The pericardial biopsy has opened a new perspective for the etiologic diagnosis of pericardial effusions, because adequate pericardial visualization via the use of a video camera can provide more accurate results. We assessed the usefulness of videopericardioscopy for the diagnosis and treatment of pericardial effusion of indeterminate origin. Methods. We conducted a retrospective study of clinical data from patients who underwent videopericardioscopy examination for pericardial effusion without an established diagnosis. The video-assisted pericardioscopy procedure was performed through a small incision in the xiphoid area. Results. From January 1998 to January 2007, 101 consecutive patients underwent videopericardioscopy evaluation for pericardial effusion. Ten patients were excluded because of lack of data. Fifty men and 41 women were included ( mean age, 50 years; range, 14-76 years). All of the patients had moderate or significant pericardial effusion as demonstrated by echocardiography or computed tomography. The following diagnoses for the pericardial effusions were established: nonspecific inflammation, 50 cases ( 54.94%); neoplastic disorders, 22 cases ( 24.17%); tuberculous, 11 cases ( 12.08%); bacterial inflammatory process, 3 cases ( 3.29%); chylopericardial, 2 cases ( 2.19%); fungal infection, 2 cases ( 2.19%); and viral infection, 1 case ( 1.09%). Pericardioscopy evaluation provided the definitive diagnosis via the pericardial biopsy in 36.26% of the cases and via the results of fluid analyses in 13.18% of the cases; the use of both methods established the definitive diagnosis in 45.05% of the cases in this group of patients. The overall morbidity rate was 4.3%, and the most common complication was arrhythmia due to intraoperative manipulation, which ceased with the removal of the instruments from the pericardial cavity. We had 1 death, by cardiac tamponade, in the perioperative period. Conclusion. Videopericardioscopy is a safe and efficient method for obtaining a better diagnosis of and satisfactory therapeutic results for pericardial effusions of indeterminate cause, and such results are obtained via an improved exploration of the pericardial cavity.

An easy method for handling the genus Phoneutria (Araneae, Ctenidae) for venom extraction

This paper describes an easy, cheap, and safe method of capturing and handling the medically important spider Phoneutria for venom extraction. The method does not injure or kill the spider and allows the extraction of pure venom.

Absence of pathological scarring in the donor site of the scalp in burns: An analysis of 295 cases

Aim: This study aims to describe the incidence of complications on scalp from which a thin split-skin graft was harvested (0.005-0.007 in.) of the donor site in children and adult burn victims. Methods: We reviewed the medical records of 295 burn patients admitted in the Burn Unit of the Clinical Hospital of the Faculty of Medicine of Ribeirao Preto, from January 1998 to December 2007, whose scalps were used as donor site for grafts. Skin-graft thickness varied from 0.005 in. to 0.007 in. The occurrence of pathological healing was evaluated clinically and the time of epithelisation by the main surgeon and a plastic surgeon or a staff nurse. Results: Of the 295 patients whose scalps were used as donor site, 274 were followed from 6 months to 10 years after the procedure (median 18.2 months). Twenty-one patients were lost to follow-up in the first 6 months. No hypertrophic scarring or keloids on the donor site was observed. Five patients (1.82%) presented with folliculitis and two of them were evaluated with small areas of alopecia (0.7%), treated with resection of these areas and primary suture. The average time of epithelisation of the donor site was 7 days. Conclusion: The harvest of thinner split graft from the scalp is a safe procedure. (C) 2009 Elsevier Ltd and ISBI. All rights reserved.

Multiple cranial burr holes as an alternative treatment for total scalp avulsion

Total scalp avulsion is a devastating injury in clinical practice. It often occurs in female adults, being rare in children. The standard treatment for scalp avulsion is microsurgical replantation, when feasible. Coverage becomes a major problem when replantation fails or is contraindicated, resulting in significant morbidity and requiring multiple procedures. In this article, in addition to reviewing the literature, we report a historical method for obtaining skin coverage after failure of replantation. The authors report a case of a 10-year-old girl who had her scalp totally avulsed by an agricultural machine, including her right auricle. Microsurgery scalp replantation was attempted immediately after fluid resuscitation. The surgery failed probably due to the long time interval between trauma and surgery, which resulted in total ischemic time of 11 h and consequently made vascular microanastomosis impracticable. Multiple trephination of the calvarium was performed in order to expose the diploe. After 4 weeks, granulation tissue from the holes began to cover the defect, allowing the formation of a vascular bed suitable for skin grafting. Total scalp avulsion in children is seldom reported in the literature. Therefore, its management is both difficult and challenging. The exposure of the diploe with multiple burr holes is a safe and effective method for treating this injury. It may be considered, along with skin grafting, a good therapeutic alternative to be used when microsurgical replantation fails or is not feasible.

Bovine Peritoneum Protection Role on Intestinal Adhesions to a Vascular Graft: A Morphological Analysis

The present study aimed to experimentally evaluate the protection role of glycerin preserved bovine peritoneum (BP) against intestinal adhesions to a vascular graft. Experiments were performed on 24 adult rabbits, randomly dived into two groups. All animals were submitted to a vascular graft over the infra-renal aorta and vena cava. Group I (12 animals) was submitted to a BP patch on the retroperitoneal opening, between the vascular prosthetic graft and the intestinal loops. Group II (12 animals) had the retroperitoneal opening sutured. After 7, 14, 28 and 60 days, 3 animals of each group were randomly killed and the retro peritoneum, with or without the BP patch, was removed for histological analysis. The histological analysis showed that the BP stimulated a moderate to intense inflammatory reaction at the beginning of the experiments and on the 60-day evaluation, the inflammatory reaction was mild, limited to the BP border with its histological structure preserved. In conclusion, the BP is a safe and cheap interposition material to be used between vascular grafts and intestinal loops, presenting a protection role against adhesions between them.

Concurrent chemoradiotherapy with weekly paclitaxel in malignant cerebral glioma treatment

Background: Anaplastic astrocytomas (AA) and glioblastomas (GB) are the most common malignant gliomas, and despite newly developed drugs and combined treatments, they still have an adverse prognosis. Paclitaxel is a cytotoxic agent with radiosensitizing properties and exerts objective growth inhibition in glioma tumor cells. Patients and Methods: From 1998 to 2002, 61 microneuro-surgically treated patients were randomized to group I (18 GB, 14 AA) which received radiotherapy and weekly paclitaxel at dose of 100 mg/m(2), and group II (21 GB, 8 AA) which received only radiotherapy as a complementary treatment. Results: Median overall survival was 27.96 months in group I and 23.06 months in group II with no statistical difference. The 12-month survival was 81% in group I and 76% in group II. Kaplan-Meier curves of both groups did not demonstrate any difference. Analysis of each histological subgroup (AA or GB) also showed no statistical difference in the survival curves. All 427 cycles were well tolerated with no treatment-associated deaths. Conclusions: Chemoradiotherapy with weekly paclitaxel is safe and tolerable although there was no increase in the overall survival and 12-month survival of malignant glioma patients. Further investigations modulating the paclitaxel entrance and delivery into the brain should be encouraged.