Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results.

PURPOSE: Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature. METHODS: In March 2016, three consecutive male patients (mean age 46.6 years-mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded. RESULTS: All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6 min, ranging between 155 and 55 min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24 h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up. CONCLUSIONS: DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients' outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

Premenstrual syndrome and beyond: lifestyle, nutrition, and personal facts.

AIM: The aim was to study prevalence of menstrual symptoms and their presenting patterns, and to assess nutrition and behaviours correlates. METHODS: The study enrolled 108 women, who were prospectively assessed for menstrual symptoms; a 212 items questionnaire about lifestyle and nutrition was administered. Diagnosis and intensity of symptoms were separately compared for dietary and other factors. The χ2 test or Fisher exact test as required and a multivariate analysis were performed. RESULTS: Seventeen percent of the sample reported no symptoms; core PMD was diagnosed in 14%, and related to symptoms of moderate intensity, to late menarche, irregular, long cycles, dysmenorrhoea, and to lower intake of complex carbohydrates, fibers, calcium; non-cyclical pattern in 27%, and related to symptoms of severe intensity, to young age, unemployed, to poor health, stress, traumatic events, abnormal BMI, to long, heavy menses, to lower intake of fibers, magnesium, vitamin B6, and to higher intake of fat, proteins, sodium, caffeine; variant PMD-premenstrual exacerbation in 42%, and related to symptoms of severe - moderate intensity, to young age, students, unemployed, sedentary work, abnormal BMI, stress, to cycle irregularities, heavy menses, to higher intake of simple sugars and sodium, and to lower intake of calcium, magnesium, and vitamin B6. Regardless of diagnosis, severe intensity of symptoms was associated with young age /students (P<0.001), lower education, unemployed, smoke, sedentary work, poor health, stress, heavy menses (P<0.01), dysmenorrhea, more unfavorable and less favorable nutrients. CONCLUSION: Lifestyle, nutrition, and general health considerations seem to be important issues in the management of menstrual symptoms, prospective symptoms chart being mandatory for diagnosis.

Does diabetes mellitus increase the risk of high-grade prostate cancer in patients undergoing radical prostatectomy?

The objective was to test the hypothesis that in patients with prostate cancer undergoing radical prostatectomy (RP), diabetic patients are at a higher risk of harboring a high-grade tumor than non-diabetic patients. We examined 2060 consecutive men who underwent RP between 2001 and 2009. Of them, 7.1% had type 2 diabetes mellitus (DM). A high-grade tumor was defined as having a Gleason score ≥ 8. Univariable and multivariable logistic regression analyses were used to test the relationship between type 2 DM and high-grade tumor. Mean patient age was 64 years (range: 45-85). Mean total PSA level was 9 ng ml(-1) (range: 1-89.5). A significantly higher percentage of diabetic patients had high-grade tumor on biopsy (16.3 vs 7.6%; P = 0.001) and on RP specimen (21.1 vs 11.7%; P = 0.001) in comparison with non-diabetic patients. In multivariable analyses, DM was an independent predictor of high-grade tumor on biopsy (odds ratio = 2.31, P = 0.001) and on final pathological specimen (odds ratio = 2.22, P = 0.002). In patients undergoing RP, those with type 2 DM had a higher risk of harboring a poorly differentiated tumor on final pathological examination.

Open prostatectomy and the evolution of HoLEP in the management of benign prostatic hyperplasia.

Trans-urethral resection of the prostate (TURP) and other minimally invasive therapies are the most common surgical procedures used to treat benign prostatic hyperplasia today. However, many patients with a markedly enlarged prostate are often not amenable to these treatment options. In these patients open prostatectomy has been representing a viable and preferred treatment. Despite the morbidity of open enucleation is substantial, until recently no other options were available when the size of the prostate approached 100 g and beyond. The use of holmium laser for the treatment of benign prostatic hyperplasia was first reported in 1996. Holmium laser enucleation of the prostate (HoLEP) has been proposed as an alternative to TURP and to open prostatectomy for patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement. In this manuscript, the development of HoLEP from the initial reports to the long-term follow-up data which demonstrate the effectiveness of the technique in treating patients affected by LUTS secondary to large adenomas has been reviewed. HoLEP seems to represent a valid alternative to both TURP and OP, with valid long-term functional results, a low rate of short-term and long-term complications, and very low rates of reintervention. In conclusion, HoLEP can be offered as the size-independent gold standard treatment of patients with LUTS due to benign prostatic enlargement.

Comportamento térmico de alguns fármacos e medicamentos / Thermal studies of some pharmaceutical drugs

A técnica de análise térmica apresenta aplicações em diversos ramos da ciência, entre eles a indústria farmacêutica, a qual pode utilizá-la para caracterização e estudo das matérias primas e produtos finais. Os compostos farmacêuticos apresentam diferentes formas morfológicas ou estruturais,que afetam diretamente na sua estabilidade, ação e liberação. O desenvolvimento e fabricação de medicamentos requerem intenso cuidado devido a pureza, qualidade e estabilidade dos componentes. Um dos itens para se obter uma formulação estável e efetiva depende dos cuidados na escolha dos excipientes utilizados, onde uma de suas propriedades é a de interferir na biodisponibilidade e proteção do fármaco frente a degradação. Neste trabalho foram utilizadas técnicas de análise térmica (TG/DTG/DSC/DTA) e a espectroscopia Raman para estudar possíveis interações entre o fármaco e seus excipientes. Foram selecionados para o estudo os medicamentos Aspirina® e AAS®, comparados com o seu princípio ativo ácido acetil salicílico. As amostras não sofreram pré tratamento e foram analisadas como adquiridas no mercado. Os resultados obtidos através das técnicas de análise térmica evidenciaram uma possível interação entre os diferentes excipientes utilizados e o princípio ativo. Os espectros Raman corroboram com os resultados obtidos das análises térmicas dos medicamentos. Através dos resultados obtidos concluímos que as diferentes composições existentes na formulação dos medicamentos podem promover mudanças em suas propriedades físicas e consequentemente na sua atividade biológica.

Uranium incorporation biokinetics in poultry bonesas function of phytase doses

Direct alpha-energy spectroscopy in liquids is possible by placing a chemically selective polymer thin film upon the surface of passivated silicon diodes. By utilizing polymer thin films with high affinity for actinides, we have been able to selectively concentrate actinides of interest upon the diode surface, resulting in a substantial increase in sensitivity relative to a direct measurement. With this film coated diodes, we were able to obtain in-situ alpha spectra with energy resolution comparable to that of conventional alpha-spectroscopy. The response of the thin film coated diode was found to be linear over . The sensitivity and reversibility is a function of the membrane complexation chemistry.

Long-term accumulation of uranium in bones of Wistar rats as a function of intake dosages.

Groups of Wistar rats were fed with ration doped with uranyl nitrate at concentration A ranging from 0.5 to 100 ppm, starting after the weaning period and lasting until the postpuberty period when the animals were sacrificed. Uranium in the ashes of bones was determined by neutron activation analysis. It was found that the uranium concentration in the bones, as a function of A, exhibits a change in its slope at approximately 20 ppm-a probable consequence of the malfunctioning of kidneys. The uranium transfer coefficient was obtained and an analytical expression was fitted into the data, thus allowing extrapolation down to low doses. Internal and localized doses were calculated. Absorbed doses exceeded the critical dose, even for the lowest uranium dosage.

Long-term accumulation and microdistribution of uranium in the bone and marrow of beagle dog.

The accumulation and microdistribution of uranium in the bone and marrow of Beagle dogs were determined by both neutron activation and neutron-fission analysis. The experiment started immediately after the weaning period, lasting till maturity. Two animal groups were fed daily with uranyl nitrate at concentrations of 20 and 100 microg g(-1) food. Of the two measuring techniques, uranium accumulated along the marrow as much as in the bone, contrary to the results obtained with single, acute doses. The role played by this finding for the evaluation of radiobiological long-term risks is discussed. It was demonstrated, by means of a biokinetical approach, that the long-term accumulation of uranium in bone and marrow could be described by a piling up of single dose daily incorporation.

Laparoscopic treatment of adrenal diseases: 10 years on.

Since it was initially described in 1992 laparoscopic adrenalectomy (LA) has been gaining popularity amongst urologists and its range of applications has progressively widened. Ten years after the first report of LA this type of operation is presently considered to be the 'standard of care' for most adrenal diseases requiring surgery. We define the current role of laparoscopy in the management of surgical adrenal diseases, using a Medline search (1997-2002) to assess reports of LA, focusing on indications, approaches (transperitoneal and retroperitoneoscopic) and comparative analyses, taking particular care to evaluate operative duration, rate of conversion and transfusion, complications and hospital stay. With both approaches LA is safe and effective and, when compared with open surgery, offers the same functional results with all the advantages of minimally invasive surgery. We conclude that LA based on either approach should be considered the treatment of choice for benign adrenal lesions. Although very promising, conservative surgery and LA should still be evaluated in cases of malignancy.

The ageing male and erectile dysfunction.

Erectile dysfunction is common in the ageing man and reliable therapies are needed. The pathophysiology of erectile dysfunction in this group mainly includes chronic ischaemia, which triggers the deterioration of cavernosal smooth muscle and the development of corporeal fibrosis. Assessing the ageing man with erectile dysfunction who seeks medical treatment should comprise a thorough medical and sexual history, a systemic and focused physical examination and selected blood tests. Oral drug therapy represents a safe and effective option for most ageing men.

Pharmacological management of erectile dysfunction.

Erectile dysfunction (ED) is a common medical condition that affects the sexual life of millions of men worldwide. Many drugs are now available for treating ED; oral pharmacotherapy represents the first-line option for most patients with ED. Sildenafil, an inhibitor of the enzyme phosphodiesterase type 5, is currently the most widely prescribed oral agent and has a very satisfactory efficacy-safety profile in all patient categories. Apomorphine SL is a dopamine D1- and D2-receptor agonist which has recently been approved for marketing in Europe. It is best selected for treating patients with mild to moderate ED. Vardenafil and tadalafil are new phosphodiesterase type 5 inhibitors which are expected to be approved this year. Both of them have significant positive efficacy-safety profiles. Patients who do not respond to oral pharmacotherapy or who cannot use it are good candidates for intracavernosal and intraurethral therapy. Alprostadil is the most widely used drug, both for injection therapy and for the intraurethral route. The efficacy of second-line treatment is high but the attrition rate remains significant.

Current status of local penile therapy.

Guidelines for management of patients with erectile dysfunction indicate that intraurethral and intracavernosal injection therapies represent the second-line treatment available. Efficacy of intracavernosal injections seems superior to that of the intraurethral delivery of drugs, and this may explain the current larger diffusion of the former modality. Safety of these two therapeutic options is well established; however, the attrition rate with these approaches is significant and most patients eventually drop out of treatment. Newer agents with better efficacy-safety profiles and using user-friendly devices for drug administration may potentially increase the long-term satisfaction rate achieved with these therapies. Topical therapy has the potential to become a first-line treatment for erectile dysfunction because it acts locally and is easy to use. At this time, however, the crossing of the barrier caused by the penile skin and tunica albuginea has limited the efficacy of the drugs used.

Reconfiguration of the severely fibrotic penis with a penile implant.

PURPOSE: Using evidence based methods we prospectively evaluated the impact of a new surgical procedure on penile deformity caused by severe cavernous fibrosis. MATERIALS AND METHODS: In 10 patients with severe penile curvature, shortening and impaired penile rigidity due to fibrosis of the corpora cavernosa we made multiple relaxing incisions of the tunica albuginea and subsequently placed a 3-piece inflatable penile implant. Patients were evaluated before and after the procedure by the International Index of Erectile Function and several general assessment questions. Preoperatively and postoperatively we measured flaccid and erect penile length. RESULTS: At the 6-month followup all International Index of Erectile Function domains were significantly improved compared with preoperative values. Average penile length was increased 2.3 and 3 cm. while flaccid and erect, respectively, compared with before surgery. Complete penile straightening was achieved in 9 of 10 cases (90%). Surgical reoperation was performed in 1 patient (10%) in whom the implant was removed due to scrotal infection and in another (10%) in whom a further single relaxing incision of the fibrotic plaque was needed to attain complete penile straightening. CONCLUSIONS: Patients with severe penile curvature, shortening and impaired penile rigidity due to penile fibrosis may be offered this surgical alternative, which proved to be effective and safe in our preliminary series.

Eight-year experience with transperitoneal laparoscopic adrenal surgery.

PURPOSE: Laparoscopic adrenalectomy is currently the technique of choice for removing benign adrenal lesions. Various laparoscopic techniques and approaches have been reported using the transperitoneal or retroperitoneal approach. We present our 8-year experience with and long-term results of transperitoneal laparoscopic adrenalectomy. MATERIALS AND METHODS: Between October 1992 and October 2000, 161 laparoscopic approaches to the adrenal gland were performed, including 145 unilateral and 10 bilateral adrenalectomies, and 6 conservative operations. Patients were placed in the 60-degree flank position with the bed flexed to increase the surgical field. To avoid hypertensive crisis, especially in patients with pheochromocytoma, the first step involved early ligation of the adrenal vein. RESULTS: The laparoscopic procedure was successfully completed in all except 4 cases, which were converted to open surgery. Mean operative time was 160 minutes in the unilateral, 245 in the bilateral and 90 in the conservative group. Delayed complications included hemoperitoneum in 3 patients, which was drained surgically, severe blood loss in 3 treated with blood transfusion and wound infection in 2. Patients were ambulatory on the morning of postoperative day 1 and were discharged home 2.8, 5 and 1.8 days after unilateral, bilateral and conservative surgery, respectively. CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe, effective, minimally invasive approach in patients with benign functioning or nonfunctioning adrenal masses. This technique involves low morbidity, minimal postoperative analgesic requirements and a short hospital stay.

Current role of laparoscopic adrenalectomy.

OBJECTIVE: Laparoscopic adrenalectomy is now a standard procedure for the vast majority of patients with surgical adrenal disease. Herein, we evaluate various techniques employed during laparoscopic adrenalectomy, and assess the current role of laparoscopic adrenalectomy, and possible future developments. MATERIALS AND METHODS: We reviewed large series of reports presenting the results of laparoscopic transperitoneal and retroperitoneal adrenalectomy and we compared the data of different series and authors, adding our experience. RESULTS: Laparoscopic adrenalectomy is a safe, reproducible and effective procedure with low complication rates. With increasing worldwide experience, the indications for laparoscopic adrenalectomy are expanding. When retrospectively compared to open surgery, laparoscopic adrenalectomy is superior in terms of postoperative pain, hospital stay, return to normal activity and complications. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective option for most surgical adrenal pathologies. Moreover, laparoscopic adrenalectomy is associated with a superior patient tolerance profile. It is safe to say that today, laparoscopy must be considered the first choice procedure for excision of benign surgical adrenal lesions.

Transfer coefficient measurements of uranium to the organs of Wistar rats, as a function of the uranium content in the food.

Groups of animals (Wistar rats) were fed with rations doped with uranyl nitrate at concentrations ranging from 0.5 to 100 ppm. The uranium content in the ashes of the organs was measured by the neutron-fission track counting technique. The most striking result is that the transfer coefficients, as a function of the uranium concentration, exhibit a concave shape with a minimum around 20 ppm-U for all organs. Explanations to interpret this finding are tentatively given.

Use of the laparoscopic knot introducer in urethrovesical anastomosis following radical prostatectomy.

One of the most delicate stages of retropubic radical prostatectomy intervention is urethrovesical anastomosis, especially if it is performed in a deep bony pelvis with a short urethral stump. Correct knot tying is essential to avoid the risk of postoperative anastomotic leakage. In such conditions, the urethrovesical anastomosis is performed with six 4-0 Monocril sutures and the knots are tied under vision using the laparoscopic knot introducer. In a 2-year period we performed 106 retropubic radical prostatectomies in our urology department. In four cases (3.8%) we performed urethrovesical anastomosis with the aid of the described technique. Two weeks after catheter placement, the radiologic control showed no leakage or contracture of the anastomosis. Mean follow-up is 14.8 months (range 8 to 20); all of the patients are continent. A second radiologic study 6 months after the intervention documented in all cases a correct new anatomical repair without stenoses or contracture. This technique is a minor modification of the direct urethrovesical anastomosis that facilitates the anastomosis between the urethral stump and the bladder neck and reduces the risk of anastomotic leakage due to incorrect suture knot positioning and tying.

Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet.

OBJECTIVE: To evaluate the impact of the route of administration of artificial nutrition and the composition of the diet on outcome. DESIGN: Prospective, randomized, clinical trial. SETTING: Department of surgery, university hospital. PATIENTS: One hundred sixty-six consecutive patients undergoing curative surgery for gastric or pancreatic cancer. INTERVENTIONS: At operation, the patients were randomized into three groups to receive: a) a standard enteral formula (control group; n = 55); b) the same enteral formula enriched with arginine, RNA, and omega-3 fatty acids (enriched group; n = 55); and c) total parenteral nutrition (TPN group; n = 56). The three regimens were isocaloric and isonitrogenous. Enteral nutrition was started within 12 hrs following surgery. The infusion rate was progressively increased to reach the nutritional goal (25 kcal/kg/day) on postoperative day 4. MEASUREMENTS AND MAIN RESULTS: Tolerance of enteral feeding, rate and severity of postoperative complications, and length of hospital stay were recorded. Early enteral infusion was well tolerated. Side effects were recorded in 22.7% of the patients, but only 6.3% did not reach the nutritional goal. The enriched group had a lower severity of infection than the parenteral group (4.0 vs. 8.6; p < .05). In subgroups of malnourished (n = 78) and homologous transfused patients (n = 42), the administration of the enriched formula significantly reduced both severity of infection and length of stay compared with the parenteral group (p < .05). Moreover, in transfused patients, the rate of septic complications was 20.0% in the enriched group, 38.4% in the control group, and 42.8% in the TPN group. CONCLUSIONS: Early enteral feeding is a suitable alternative to TPN after major abdominal surgery. The use of the enriched diet appears to be more beneficial in malnourished and transfused patients.

Gut function and immune and inflammatory responses in patients perioperatively fed with supplemented enteral formulas.

OBJECTIVE: To evaluate if the perioperative administration of a supplemented enteral formula modulates selective inflammatory and immune variables and gut function after surgery. DESIGN: Prospective, randomized, double-blind, clinical trial. SETTING: Department of surgery, university hospital. PATIENTS: Forty patients with neoplasm of the colorectum or stomach. INTERVENTION: Seven days before surgery, the patients drank 1 L/d of a control enteral formula (n = 20) or the same formula enriched with arginine, RNA, and omega-3 fatty acids (n = 20). Jejunal infusion with the same formulas was started 6 hours after operation and continued until day 7. MAIN OUTCOME MEASURES: Immune response was determined by phagocytosis ability and respiratory burst of polymorphonuclear cells, and inflammatory response by plasma levels of C-reactive protein. Operative intestinal microperfusion, postoperative intestinal mucosa oxygen metabolism, and plasma intestinal isoenzyme of alkaline phosphatase were used as indicators of gut function. Plasma nitric oxide also was determined. RESULTS: In the enriched group, phagocytosis ability and respiratory burst after surgery was higher (P < .01) and C-reactive protein level was lower (P < .05) than in the control group. The enriched group had higher mean (+/-SD) intestinal microperfusion (180 +/- 46 vs 146 +/- 59 perfusion units, P < .05), intestinal mucosa oxygen metabolism (pHi 7.39 +/- 0.2 vs pHi 7.33 +/- 0.1, P < .05), and 5-fold lower levels of intestinal isoenzyme of alkaline phosphatase (P < .05). Postoperative levels of nitric oxide were higher in the enriched group (P < .05, analysis of variance). CONCLUSION: The perioperative administration of an enriched enteral formula significantly improved gut function and positively modulated postsurgical immunosuppressive and inflammatory responses.

Immune and nutritional effects of early enteral nutrition after major abdominal operations.

AIM: To investigate the effect of early postoperative enteral nutrition enriched with arginine, RNA and omega-3 fatty acids on immunological and nutritional variables after elective curative operations for gastric or pancreatic cancer. DESIGN: Randomised controlled trial. SETTING: University hospital, Italy. SUBJECTS: 78 Consecutive patients who were to undergo curative operations for gastric or pancreatic cancer, 60 of whom were suitable for the study. INTERVENTIONS: Patients were randomly allocated to three groups (n = 20 each) according to the type of postoperative nutritional support: standard enteral diet, the same diet enriched with arginine, RNA, and omega-3 fatty acids or total parenteral nutrition. The daily nutritional goal was 25 kcal (105 kJ)/kg and 0.25 g nitrogen/kg for all patients. MAIN OUTCOME MEASURES: Serum concentrations of immunoglobulins, albumin, transferrin, prealbumin, retinol binding protein (RBP); cholinesterase activity, weight loss, duration of operation, operative blood loss; blood transfusion; delayed hypersensitivity responses, number of lymphocyte subsets, phagocytic ability of monocytes, number of interleukin-2 (IL-2) plasma receptors, interleukin-6 (IL-6) plasma concentrations, postoperative infections and sepsis scores. RESULTS: All enterally fed patients but one completed the nutritional programme. There were significant postoperative reductions in both nutritional and immunological variables in all groups. On postoperative days 4 and 8 prealbumin concentration (p < 0.05), RBP concentration (p < 0.05), delayed hypersensitivity responses (p < 0.05), phagocytic ability of monocytes (p < 0.01) and concentration of IL-2 receptors (p < 0.009) had all recovered more in the group receiving the enriched solution. There was no difference in the postoperative infection rates among the three groups, but the infections were less severe in the enriched group (p < 0.005). CONCLUSION: Early enteral feeding was well tolerated. Patients who received the enriched solution recovered both their nutritional and immunological status quicker than those in the other two groups.