Videolaparoscopic prostatectomy in porcine model for training residents

ABSTRACT Introduction: Surgical training models prepare the resident for a more ethical surgical practice as well as providing a less steep learning curve. In urology, there are well-known models of pyeloplasty simulation, urethro-vesical anastomosis and nephrectomy, which have helped in the training of urology residents (1-3). Learning laparoscopic prostatectomy is a difficult surgery and requires advanced surgical skill from the surgeon (4), requires operate without a direct view of the surgical field in a two-dimensional space and with longer instruments (5). Laparoscopic prostatectomy step by step makes the surgeon's learning curve less difficult, lead to less intraoperative complications, such as blood loss, while also enabling shorter operative time and less positive surgical margins (6). The objective of surgical models is to simulate surgical procedures in a reliable way thus preparing the surgeon for his daily practice, surgical simulations in animal models have been described to compensate for inadequate clinical exposure (7). The canine model of prostate cancer has many similarities with humans. Despite trying to develop a model that is as credible as possible, there are ethical issues in several countries, such as Brazil, that do not allow the use of live dogs for scientific experimentation and there is a difficulty in not standardizing the animals used (8, 9). The swine surgical training model is widely known, accepted and used as a valuable tool in the teaching of new surgeons (10). The porcine video laparoscopic prostatectomy model allows the urologist in training to exercise the skills required in a real surgical situation, practicing them in a single session (10). We will present an experimental model in pigs for training urology residents in laparoscopic radical prostatectomy with current techniques (11-13). The limitations found are that the prostate has no limits as well defined as in humans, the urethra is long and coiled, the fat surrounding the pelvic organs is scarce and there is no postoperative follow-up for evaluating functionality after the procedure, as well as the effectiveness of the surgery with surgical margins. However, it is similar in surgical model presented, it is reproducible and can provide a realistic simulation environment to the beginner surgeon. Material and Methods: In this paper, according to the institutional protocol approved by the institutional ethics and research committee FMUSP n° 964/2017 and protocol was in accordance with current international regulations for the use of animals in Research: Reporting In Vivo Experiments (ARRIVE) guide. Ten male pigs weighing 20 to 22kg were used. The animals were anesthetized with a combination of Telazol (5mg/kg), Xylazine (1.5mg/kg), Cetamine (22mg/kg) and Atropine (0.04mg/kg) for orotracheal intubation followed by Isoflurane (2%). Animals were euthanized at the end of the procedure with a lethal dose of KCl (2mEq/kg). The trocar insertion points were marked using the epigastric vessels and umbilical region as reference points. Initially, urethral catheterization was performed using a hydrophilic Nitinol guidewire, followed by a perineal incision to dissect the tortuous urethra of the porcine model. A malleable urethral catheter 8Fr was inserted into their bladder. The animal was placed in the Trendelenburg position inserted and 12mm trocars were inserted in its umbilical region, utilizing 10mm in the surgeon's dominant hand, 5mm in his non-dominant hand of the surgeon, and 5mm in the first assistant's trocar. The surgeon replicates the steps performed in a laparoscopic radical prostatectomy in humans, including the bladder catheterization, dissection of the anterior bladder plane, the vesicular and prostatic dissection, the suture of the dorsal venous plexus, a prostatectomy, an urethral vesical anast omosis, as well as the waterproof test, even including the performing of surgical steps using current concepts of anterior urethral suspension as the reconstruction of the posterior plane of the rhabdosphincter. Results: All steps of surgery could be reproduced in all ten porcine cases. No significant bleeding was observed and the surgical time was gradually reduced fifty percent from case one to last cases. Conclusions: The porcine model allowed the surgeon to replicate all the steps usually performed in a laparoscopic radical prostatectomy. The junior surgeons are better prepared to such difficult surgery. However, further studies will be necessary to prove the impact of the animal model presented in urological clinical practice.

Adipose-derived stem cells (ADSC) in the viability of a random pattern dorsal skin flap in rats

PURPOSE: To evaluate the viability of random pattern dorsal skin flaps in rats after injection of adipose-derived stem cells (ADSC). METHODS: Thirty five adult male Wistar EPM rats (weight 250-300 g) were distributed, at random, in two groups. I- Control (flap elevation with injection of saline solution) with fifteen animals and II- Experimental (flap elevation with injection of ADSC ) with fifteen animal. The ADSC were isolated from others five adult male rats. A dorsal skin flap measuring 10x4 cm was raised and a plastic barrier was placed between the flap and its bed in both groups and the injection (cells or saline solution) were perfomed immediately after the surgery. The percentage of flap necrosis was measured on the seventh postoperative day. RESULTS: The ADSC were able to replicate in our culture conditions. We also induced their adipogenic, osteogenic and chondrogenic differentiation to verify their mesenchymal stem cells potentiality in vitro. The results were statistically significant showing that the ADSC decreased the area of necrosis (p<0.05). CONCLUSIONS: The cells demonstrated adipogenic, osteogenic and chondrogenic differentiation potential in vitro. The administration of adipose-derived stem cells was effective to increase the viability of the random random pattern dorsal skin flaps in rats. .

Adipose-derived stem cells (ADSC) in the viability of random skin flap in rats

PURPOSE: To evaluate the effects of the adipose-derived stem cells (ADSC) in the viability of random skin flap in rats. METHODS: Thirty five adult male Wistar rats (weight 250-300 g) were used. ADSC were isolated from adult male rats (n=5). ADSC were separated, cultured and then analyzed. A dorsal skin flap measuring 10x4 cm was raised and a plastic barrier was placed between the flap and its bed. After the surgical procedure, the animals were randomized into two groups (n=15 each group), group control and group ADSC. In all groups the procedures were performed immediately after the surgery. The percentage of flap necrosis was measured on the seventh postoperative day. RESULTS: The ADSC were able to replicate in our culture conditions. We also induced their adipogenic, osteogenic and chondrogenic differentiation, verifying their mesenchymal stem cells potentiality in vitro. The results were statistically significant showing that the ADSC decreased the area of necrosis (p<0.05). CONCLUSION: The cells demonstrated adipogenic, osteogenic and chondrogenic differentiation potential in vitro. The administration of adipose-derived stem cells was effective to increase the viability of the random skin flaps in rats. .

Avaliação de empatia em residentes de especialidades clínicas e cirúrgicas da Universidade Federal de São Paulo / assessment of empathy in medical residents of clinic and surgical specialties at the Federal University of São Paulo

No campo da saúde, a empatia é definida como um atributo com dimensões emocionais e cognitivas que possibilita uma compreensão das experiências interiores e da perspectiva do paciente como um indivíduo singular, somada à capacidade de comunicar esse entendimento ao paciente. A função da empatia médica seria identificar e compreender os sentimentos do doente, promovendo aumento na confiança, na lealdade e no respeito entre médico e paciente. Este estudo teve como meta avaliar a empatia de residentes entre o terceiro e o quinto ano da Universidade Federal de São Paulo, buscando verificar as possíveis diferenças entre a empatia dos clínicos e cirurgiões e sua relação com o perfil profissional.

In the field of health, empathy is defined as an attribute with cognitive and emotional dimensions that enables an understanding of inner experience and a perspective of the patient as a unique individual, plus the ability to communicate this understanding to the patient. The role of empathy is to identify and understand the patient's feelings, thus promoting an increase in trust, loyalty and respect between doctor and patient. Therefore, the following study was aimed at evaluating the empathy 3rd to 5th year medical residents from the Federal University of São Paulo to verify any possible differences between the empathy of physicians and surgeons and their relationship with the professional profile.