The dangers of sexual enhancement supplements and counterfeit drugs to "treat" erectile dysfunction.

Counterfeit phosphodiesterase-5 inhibitors (PDE-5i) are an increasing problem. Already in widespread use, the market for PDE-5i is steadily growing as the population ages. Counterfeiters are taking advantage of this growing market by developing illicit and counterfeit PDE-5i products. Many factors are contributing to the rapid growth of the illicit market, such as the low risk of prosecution, potentially high financial reward, and ease of distribution via Internet pharmacies. Consumers of illicit PDE-5i often do not realize they are using counterfeit products and placing themselves at an unnecessary health risk. Others seek to bypass the legitimate healthcare system due to either embarrassment of the underlying condition or desire for cheaper alternatives. However, taking illicit PDE-5i may harm consumers directly, as many illicit products contain detrimental contaminants and inaccurate amounts of the active ingredient without the appropriate warnings. Bypassing the legitimate healthcare system also endangers consumers indirectly, as erectile dysfunction (ED) is often associated with other medical comorbidities that patients should be screened for. Furthermore, PDE-5i can have potentially dangerous interactions with other pharmaceuticals that are rarely warned against with counterfeit PDE-5i. This communication reviews the literature regarding counterfeit PDE-5i, and summarizes both the scope and dangers of the illicit PDE-5i market.

Feasibility of quantitative diffuse reflectance spectroscopy for targeted measurement of renal ischemia during laparoscopic partial nephrectomy.

Reduction of warm ischemia time during partial nephrectomy (PN) is critical to minimizing ischemic damage and improving postoperative kidney function, while maintaining tumor resection efficacy. Recently, methods for localizing the effects of warm ischemia to the region of the tumor via selective clamping of higher-order segmental artery branches have been shown to have superior outcomes compared with clamping the main renal artery. However, artery identification can prolong operative time and increase the blood loss and reduce the positive effects of selective ischemia. Quantitative diffuse reflectance spectroscopy (DRS) can provide a convenient, real-time means to aid in artery identification during laparoscopic PN. The feasibility of quantitative DRS for real-time longitudinal measurement of tissue perfusion and vascular oxygenation in laparoscopic nephrectomy was investigated in vivo in six Yorkshire swine kidneys (n=three animals ). DRS allowed for rapid identification of ischemic areas after selective vessel occlusion. In addition, the rates of ischemia induction and recovery were compared for main renal artery versus tertiary segmental artery occlusion, and it was found that the tertiary segmental artery occlusion trends toward faster recovery after ischemia, which suggests a potential benefit of selective ischemia. Quantitative DRS could provide a convenient and fast tool for artery identification and evaluation of the depth, spatial extent, and duration of selective tissue ischemia in laparoscopic PN.

Induction of cold ischemia in patients with solitary kidney using retrograde intrarenal cooling: 2-year functional outcomes.

PURPOSE: Renal hypothermia is commonly utilized during nephron sparing surgery to minimize ischemic tissue damage. We propose a method to induce renal hypothermia using continuous retrograde irrigation of iced saline via dual-lumen ureteral catheter. We will report results in an ex vivo porcine model followed by clinical outcomes in a series of patients with solitary kidney undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN). MATERIALS AND METHODS: First, we performed temperature measurements during retrograde renal cooling in a porcine model before investigating the technique in humans. In porcine experiments, renal cortical temperature measurements (n = 270) were recorded during retrograde infusion of ice-cold saline via a 10-Fr dual-lumen ureteral catheter placed in ureter. Subsequently, a series of patients (n = 10) undergoing RALPN with a solitary kidney had concomitant intra-operative retrograde renal cooling. A 10-Fr dual-lumen ureteral catheter was placed at initiation of anesthesia and cold saline initiated prior to renal artery clamping. RESULTS: Porcine cortical temperature reached the target temperature (≤20 °C) within an average of 203 s of retrograde irrigation. In the clinical series, patients' mean preoperative creatinine was 1.16 mg/dL (GFR = 60). At a median follow-up of 10 months (range 1-27 months), postoperative creatinine was 1.50 mg/dL (GFR = 41.28). Average clamp time was 19.4 min. All patients had negative surgical margins. CONCLUSIONS: Retrograde irrigation is a technically feasible method to induce cold ischemia, which may provide an additional protective effect of renal function in patients who have a solitary kidney undergoing surgery via a minimally invasive approach.

Next-generation prostate cancer biobanking: toward a processing protocol amenable for the International Cancer Genome Consortium.

Next-generation DNA and RNA sequencing requires intact nucleic acids from high-quality human tissue samples to better elucidate the molecular basis of cancer. We have developed a prostate biobanking protocol to acquire suitable samples for sequencing without compromising the accuracy of clinical diagnosis. To assess the clinical implications of implementing this protocol, we evaluated 105 consecutive radical prostatectomy specimens from November 2008 to February 2009. Alternating levels of prostate samples were submitted to Surgical Pathology as formalin-fixed, paraffin-embedded blocks and to the institutional biobank as frozen blocks. Differences in reported pathologic characteristics between clinical and procured specimens were compared. Clinical staging and grading were not affected by the biobank protocol. Tumor foci on frozen hematoxylin and eosin slides were identified and high-density tumor foci were scored and processed for DNA and RNA extractions for sequencing. Both DNA and RNA were extracted from 22 cases of 44 with high-density tumor foci. Eighty-two percent (18/22) of the samples passed rigorous quality control steps for DNA and RNA sequencing. To date, DNA extracted from 7 cases has undergone whole-genome sequencing, and RNA from 18 cases has been RNA sequenced. This protocol provides prostate tissue for high-throughput biomedical research and confirms the feasibility of actively integrating prostate cancer into The Cancer Genome Atlas Program, a member of the International Cancer Genome Consortium.

Emergency department lactate is associated with mortality in older adults admitted with and without infections.

OBJECTIVES: Serum lactate values in the emergency department (ED) have been associated with mortality in diverse populations of critically ill patients. This study investigates whether serum lactate values measured in the ED are associated with mortality in older patients admitted to the hospital, both with and without infections. METHODS: This is a retrospective cohort study performed at two urban teaching hospitals. The study population includes 1,655 older ED patients (age>or=65 years) over a 3-year period (2004-2006) who had serum lactate measured prior to admission. The presence or absence of infection was determined by review of International Classification of Diseases Ninth Revision (ICD-9) admission diagnosis codes. Mortality during hospitalization was determined by review of inpatient records. Mortality at 30 and at 60 days was determined using a state death registry. RESULTS: In patients with infections, increasing serum lactate values of >or=2.0 mmol/L were linearly associated with relative risk (RR) of mortality during hospitalization (RR=1.9 to 3.6 with increasing lactate), at 30 days (RR=1.7 to 2.6), and at 60 days (RR=1.4 to 2.3) when compared to patients with serum lactate levels of <2.0 mmol/L. In patients without infections, a similar association was observed (RR=1.1 to 3.9 during hospitalization, RR=1.2 to 2.6 at 30 days, RR=1.1 to 2.4 at 60 days). In both groups of patients, serum lactate had a greater magnitude of association with mortality than either of two other commonly ordered laboratory tests, leukocyte count and serum creatinine. CONCLUSIONS: Higher ED lactate values are associated with greater mortality in a broad cohort of admitted patients over age 65 years, regardless of the presence or absence of infection.

Double-pigtail stenting of the ureters: technique for securing the ureteral orifices during robot-assisted radical prostatectomy for large median lobes.

Patients with large median prostate lobes undergoing robot-assisted radical prostatectomy are at potential risk of ureteric orifice injury, during posterior bladder neck transection and vesicourethral anastomosis reconstruction. We describe our technique of in situ robot-assisted ureteral stenting with double-pigtail stents for accurate observation and preservation of the ureteral orifices. We have performed this maneuver in over 30 patients in our cohort of over 1500 patients undergoing robot-assisted radical prostatectomy to date--none of these patients developed urinary leak or bladder neck contracture, and had uneventful cystoscopic removal of stents at 6 weeks after surgery.

Real time monitoring of temperature changes in neurovascular bundles during robotic radical prostatectomy: thermal map for nerve-sparing radical prostatectomy.

OBJECTIVE: A rise in temperature of more than 55 degrees C in tissues, even for short a duration has been implicated in irreversible tissue damage. This study was aimed at recording real time temperature changes at the neurovascular bundle (NVB) during the use of cautery in robotic radical prostatectomy. METHODS: The temperature was monitored with a needle electrode in 15 cases of athermal nerve sparing and 10 cases of non-nerve sparing robotic radical prostatectomy (RRP). The needle was placed in the peritoneal cavity through the camera port and inserted around the NVB. Body temperature was recorded by nasal cannula and compared with the baseline temperature at the neurovascular bundle. The distance of the needle probe from the area of cautery use, changes in temperature at the neurovascular bundle and the duration of cautery use was recorded during the use of monopolar and bipolar current in tissue dissections. RESULTS: The mean baseline temperature at the neurovascular bundle was 0.8 degrees C lower than the body temperature. Average duration for cautery use at the anterior bladder neck and NVB with monopolar and bipolar current was 53.6 (45-65) and 79.8 (70-92) and 56.8 (45-60) and 65.7 seconds (59-76) respectively. The mean temperature rise during bladder neck dissection (distance more than 1 cm) was 43.6 degrees C [36.4-47.3 degrees C] with the monopolar and 38.8 degrees C [36.8 degrees-42.6 degrees C] with bipolar. During NVB dissection, the mean temperature rise was 53.6 degrees C (45.1 to 68.1 degrees C) with monopolar and 60.91 degrees C (47.2 to 109.8 degrees C) with bipolar. Though this difference was not significant, the mean time to return to baseline temperature was 3 seconds more with bipolar than monopolar. CONCLUSIONS: Bipolar cautery may not be safer than monopolar because of a greater rise in temperature of surrounding tissues within 1 cm of its use. Further investigation is needed to fully establish the pathologic consequences associated with increased temperature due to cautery.