Therapeutic hypothermia after cardiac arrest - implementation in UK intensive care units.

A telephone survey was carried out to determine how many United Kingdom intensive care units were using therapeutic hypothermia as part of their management of unconscious patients admitted after cardiac arrest. All 247 intensive care units listed in the 2008 Directory of Critical Care Services were contacted to determine how many units were using hypothermia as part of their post-cardiac arrest management and how it was implemented. We obtained information from 243 (98.4%) of the intensive care units. At the time of the study, 208 (85.6%) were using hypothermia as part of post-cardiac arrest management. There has been a steady increase annually in the number of units performing therapeutic cooling from 2003 to date, with the majority of units starting in 2007 or 2008. The International Liaison Committee on Resuscitation guidelines, which recommend the use of therapeutic hypothermia for comatose patients following successful resuscitation from cardiac arrest, have taken at least 4-5 years to achieve widespread implementation in the United Kingdom.

Laparoscopic retroperitoneal lymph node dissection for low-stage testicular cancer.

BACKGROUND AND PURPOSE: Current management options for low-stage mixed malignant germ-cell testicular tumors (MMGCT) after radical orchiectomy include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The open RPLND is the surgical gold standard and has been duplicated laparoscopically with confirmed diagnostic effectiveness; however, its therapeutic oncologic value in MMGCT has never been proven. We present our laparoscopic RPLND (L-RPLND) data for low-stage MMGCT and paratesticular rhabdomyosarcoma. PATIENTS AND METHODS: Retrospective chart reviews were performed for patients who underwent L-RPLND at our institution for low clinical stage MMGCT and paratesticular rhabdomyosarcoma from May 2003 to December 2007. Patient data were compiled for surgical and clinical variables. RESULTS: A total of 26 L-RPLND procedures were completed, 3 for paratesticular rhabdomyosarcoma. Mean operative time was 250 minutes (range 176-369 min); estimated blood loss was 145 mL (range 50-500 mL); lymph node count was 23.8 (range 8-48); and hospital stay was 1.5 days (range 1-3 d). Four patients underwent postchemotherapy L-RPLND for residual nodes (1.1-2.9 cm). There were no conversions to an open procedure, blood transfusions, or operative complications. Chemotherapy was instituted in five of six patients with pathologic stage II disease. Mean follow-up was 23.7 months without retroperitoneal disease recurrence. CONCLUSION: L-RPLND as a diagnostic and therapeutic tool provides the benefits of a minimally invasive approach to MMGCT. It is the procedure of choice at our institution for low-stage MMGCT and paratesticular rhabdomyosarcoma.

Robotic partial nephrectomy: a multi-institutional analysis.

Laparoscopic partial nephrectomy for kidney tumors has demonstrated durable oncologic and functional outcomes. The feasibility of robotic partial nephrectomy (RPN) has been demonstrated in several small, single-institution studies. We performed a large, multi-institutional analysis to determine early oncologic results and perioperative outcomes after RPN. Between October, 2002 and September, 2007, 148 patients underwent RPN at six different centers by nine different primary surgeons for localized renal tumors. Medical and operative records were reviewed for clinical characteristics, pathologic findings, and follow-up information. A total of 148 patients underwent RPN. Mean tumor size was 2.8 cm. Renal hilar clamping was utilized in 120 patients, with a mean warm ischemia time of 27.8 min. Positive surgical margins were identified in six patients (4%), of which two had cautery artifact obscuring the margin after off-clamp cautery excision and one underwent completion radical nephrectomy with no evidence of cancer. There is no evidence of tumor recurrence at mean follow-up of 7.2 months (range 2-54 months) overall, and mean follow-up of 18 months (range 12-23 months) for patients with positive surgical margin. Complications occurred in nine patients (6.1%), including hematoma requiring drainage (n = 1), prolonged ileus (n = 3), pulmonary embolus (n = 2), prolonged urine leak (n = 2), and rhabdomyolysis (n = 1). Two patients underwent open conversion for failure to progress, one patient with morbid obesity and one patient with adhesions from prior ureterolithotomy. Mean hospital stay was 1.9 days. In this multi-institutional series of surgeons beginning their initial experience in RPN, the procedure is a feasible option for minimally invasive, nephron-sparing surgery, with immediate oncologic results and perioperative outcomes comparable with more mature laparoscopic series.

Robotic pyeloplasty: a critical appraisal.

BACKGROUND: Laparoscopic pyeolplasty has become a minimally invasive alternative to open pyeloplasty. Due to technical concerns with intracorporeal suturing, robotic pyeloplasty has become an emerging alternative. METHODS: The literature was reviewed for reports and outcomes on robotic pyeloplasty. RESULTS: Reports of robotic pyeloplasty are increasing, and outcomes appear excellent. CONCLUSIONS: Robotic pyeloplasty is feasible with excellent outcomes. Challenges remain in making the procedure cost effective.

Dual-organ ablative surgery using a hand-assisted laparoscopic technique. A report of four cases.

In clinical situations where more than one procedure is required, a properly positioned hand-assist device can be used to obviate the need for two large incisions. We present four cases of hand-assisted laparoscopic nephrectomy combined with a simultaneous second organ extraction. Each of the four primary procedures, as well as one of the four secondary procedures, was performed using a hand-assisted laparoscopic technique. In two cases, the secondary procedure was performed with an open surgical technique through the hand-assist incision. For the remaining secondary procedure, we used a laparoscopically assisted technique.

Ureteral access for upper urinary tract disease: the access sheath.

Ureteral access with the flexible ureteroscope remains a challenge for the urologist. The routine use of a newly developed, site-specific ureteral access sheath facilitates entry into the ureter for fragmentation and basket extraction of ureteral and renal calculi. The step-by-step technique of ureteral access with the Access Sheath is described.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Concomitant laparoscopic hand-assisted radical nephrectomy and open radical prostatectomy using a single lower midline incision.

The hand-assist technique offers the urologic surgeon several advantages. The technique provides the novice laparoscopist a logical segue into minimally invasive surgery by literally allowing one hand to remain in the realm of open surgery. Hand-assist access affords the laparoscopist the use of tactile sensation and blunt manual dissection and retraction. We describe an additional benefit of the hand-assist technique. In clinical situations in which more than one procedure is required, a properly positioned hand-assist device will avoid the need for two large incisions. We present simultaneous hand-assisted laparoscopic radical nephrectomy and open radical prostatectomy performed through a single midline incision.

Hormonal manipulation for rising PSA after radical prostatectomy.

PSA recurrence after radical prostatectomy usually indicates recurrent prostate cancer. Identification of the recurrence site is difficult, but pathological and clinical features may suggest local versus distant recurrence. Radiographic techniques including transrectal ultrasonography, and 111indium capromab pendetide scans may help identify recurrences. The use of hormonal manipulation for rising PSA after radical prostatectomy is controversial. Androgen deprivation has been a mainstay of the management for advanced prostate cancer. The timing of such therapy is debatable, and early therapy in an asymptomatic patient may not correlate with improved survival. Maximal androgenic blockade with castration and nonsteroidal antiandrogens may offer a modest survival benefit in selected patients. Novel potency-sparing therapies with antiandrogens and finasteride afford an improved patient lifestyle, with questionable effects on survival. Intermittent androgen suppression is an experimental treatment modality that may reduce the side effects of castration. Ongoing studies are being performed to clarify these controversies, and the variety of treatment options allows patients great flexibility in considering quality of life and effective cancer control.

Carbon fiber debris within the synovial joint. A time-dependent mechanical and histologic study.

The consequences of release of carbon debris within the synovial joint are of interest to surgeons contemplating the intra-articular repair of cruciate-deficient knees with a carbon fiber-based material. Coverage of carbon fiber implants with absorbable polymer as well as autogeneic graft material has resulted in surgical procedures that minimize potential fiber release. However, finite risk of release of fiber debris certainly exists. With this in mind, a controlled animal experiment to model debris release in the synovial joint was performed. As a positive control, magnesium tetrasilicate (talc) in suspension was injected into the knees of rabbits. Talc produced a transient synovitis severe enough to alter the mechanical properties of the joint cartilage. Carbon fiber debris, when similarly injected, also produced a synovitis. However, the synovitis induced by carbon particulate was not of sufficient severity or duration to alter the mechanical properties of the cartilage. Neither talc nor carbon fiber debris appeared to physically abrade cartilage.