Robot-assisted radical cystectomy with totally intracorporeal urinary diversion: surgical and early functional outcomes through the learning curve in a single high-volume center.

The aim of the study is to report surgical and early functional outcomes of first 100 patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD) in a single center. The main surgeon (A.P.) attended a modular training program at a referring center mentored by a worldwide-recognized robotic surgeon (P.W.). The program consisted of: (a) 10 h of theoretical lessons; (b) video session (c) step-by-step in vivo modular training. Each procedure was performed as taught, without any technique variation. Demographics, intra-operative data and post-operative complications, along with early functional outcomes, were recorded for each patient. We retrospectively evaluated the first consecutive 100 patients submitted to RARC with totally ICUD from July 2015 to December 2018. Median age at surgery was 69 years (IQR 60-74). 52 (52%), 32 (32%), and 17 (17%) patients received orthotopic neobladder, ileal conduit and uretero-cutaneostomy, respectively. Median operative time was 410 min. A median number of lymph nodes retrieved were 27 and median estimated blood loss was 240 mL with median hospitalization time of 7 days. All procedures were completed successfully without open conversion. A statistically significant improvement was found in the late (30-90 post-operative days) post-operative complications (p = 0.02) and operative time for urinary derivation. At multivariate logistic regression model ASA score ≥ 3 (OR = 4.2, p = 0.002) and number of lymph nodes retrieved (OR = 1.16, p = 0.02) were found to be predictors of 90-day complications. An adequate modular training is paramount to obtain successful results and reduce the learning curve of RARC, as demonstrated by our experience.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

ABSTRACT Objectives The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). Materials and methods From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. Results All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). Conclusions The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes.

OBJECTIVES: The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). MATERIALS AND METHODS: From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. RESULTS: All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). CONCLUSIONS: The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Effect of pelvic inclination and torsional deformity on canine acetabular morphology with computed tomography. A phantom study.

OBJECTIVES: To evaluate how the inclination and torsional deformity of the hemipelvis using extra-rotation as a model affect acetabular angle (AA) and dorsal acetabular rim angle (DARA) assessment with computed tomography (CT). METHODS: A normal canine hemipelvis positioned in dorsal recumbency was scanned with a 16-slice multidetector CT scanner, with different degrees of torsional deformity, using extra-rotation around the long axis (0-5-10-15°) of the hemipelvis. Each degree of extra-rotation was acquired at 0°, +20° and -20° of gantry tilt, to mimic different pelvic inclinations on its transverse axis. Cranial and central individual acetabular angles (IAA) and central DARA were calculated and correlated with inclination and torsional deformity. RESULTS: A very strong negative correlation was found between cranial and central IAA, pelvic inclination, and torsional deformity. A very strong positive correlation was found between DARA, pelvic inclination, and torsional deformity. CLINICAL SIGNIFICANCE: Pelvic inclination and torsional deformity affect acetabular angles assessment with CT. The greater the inclination (ilia far from the tabletop in dorsal recumbency) and torsional deformity of the pelvis, the worse the acetabulum appeared. A standardized scanning protocol for acetabular morphology assessment is needed and it should consider pelvic inclination. The actual relevance of pelvic torsional deformity is not well known and it should be investigated more thoroughly.

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort.

INTRODUCTION: Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. MATERIALS AND METHODS: A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. RESULTS AND LIMITATIONS: 467 patients were enrolled. Median age was 70 years (range 35-89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002-1.007 per minute; p = 0.0001). CONCLUSIONS: In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

Reticulocytes in untreated obstructive sleep apnoea.

BACKGROUND AND AIM: The short, repetitive hypoxaemic episodes observed in obstructive sleep apnoea (OSA) may determine small augmentations in mature red blood cells. It is unknown whether they affect reticulocyte release. This study explored whether the number and degree of maturation of circulating reticulocytes may be altered in OSA, possibly through the effect of erythropoietin. METHODS: Fifty male adult patients with suspected OSA, normoxic during wakefulness, were studied. After nocturnal polysomnography, a blood sample was withdrawn for blood cells count, erythropoietin, iron and transferrin determination. Reticulocyte concentration and degree of immaturity [high (H), medium (M), or low (L)] were also determined. Immature reticulocyte fraction (IRF) was calculated as (M+H) percentage of reticulocytes. RESULTS: A wide range of OSA severity was found [apnoea/hypopnoea index (AHI): 44.3 +/- 30.4, range 0.3-105; sleep time spent at oxyhaemoglobin saturation <90%: 18.1 +/- 22.2%, range 0-81%]. Both reticulocyte count and IRF slightly exceeded the normal range. Patients with a reticulocyte concentration > 2% had higher EPO levels (p < 0.05), but not worse nocturnal desaturations, than those with values < 2%. By contrast, subjects with IRF < 15% showed worse desaturations (p < 0.05), but similar EPO concentrations, when compared to subjects whose IRF was < 10%. At univariate analysis, reticulocyte count correlated to erythropoietin, while IRF to transferrin saturation, BMI and OSA severity. At multiple regression, only lowest nocturnal oxygen saturation remained a significant contributor to IRF (r2 0.223, p < 0.05). CONCLUSIONS: This data suggests that hypoxaemia due to OSA could influence the release of immature reticulocytes, but this effect is not mediated by erythropoietin.

Baroreflex control of heart rate during sleep in severe obstructive sleep apnoea: effects of acute CPAP.

Baroreflex control of heart rate during sleep (baroreflex sensitivity; BRS) has been shown to be depressed in obstructive sleep apnoea (OSA), and improved after treatment with continuous positive airway pressure (CPAP). Whether CPAP also acutely affects BRS during sleep in uncomplicated severe OSA is still debatable. Blood pressure was monitored during nocturnal polysomnography in 18 patients at baseline and during first-time CPAP application. Spontaneous BRS was analysed by the sequence method, and estimated as the mean sequence slope. CPAP did not acutely affect mean blood pressure or heart rate but decreased cardiovascular variability during sleep. Mean BRS increased slightly during CPAP application (from 6.5+/-2.4 to 7.5+/-2.9 ms x mmHg(-1)), mostly in response to decreasing blood pressure. The change in BRS did not correlate with changes in arterial oxygen saturation or apnoea/hypopnoea index. The small change in baroreflex control of heart rate during sleep at first application of continuous positive airway pressure in severe obstructive sleep apnoea was unrelated to the acute resolution of nocturnal hypoxaemia, and might reflect autonomic adjustments to positive intrathoracic pressure, and/or improved sleep architecture. The small increase in baroreflex control of heart rate during sleep may be of clinical relevance as it was accompanied by reduced cardiovascular variability, which is acknowledged as an independent cardiovascular risk factor.

Preference for fixed or automatic CPAP in patients with obstructive sleep apnea syndrome.

BACKGROUND: The aims of this study were to compare compliance to treatment with fixed CPAP and with autoCPAP, subjective preference for type of CPAP treatment, and factors associated to preference for autoCPAP in patients with OSAS. PATIENTS AND METHODS: Twenty-two subjects were studied in a randomized, single blind cross-over fashion. They were treated for one month by fixed CPAP (Elite Sullivan V, ResMed, Sydney, Australia) and one month by autoCPAP (Autoset T, ResMed, Sydney, Australia). RESULTS: Four subjects who stated a preference for fixed CPAP and four who expressed no preference were pooled together; fourteen preferred autoCPAP. Compliance to treatment using the two machines did not differ in the first group (3.8 (1.9) vs. 3.8 (1.5)h/day, fixed vs autoCPAP), but was higher with autoCPAP in the second group (4.8 (1.8) vs 5.5 (1.5)h/day, P<0.05). Baseline apnea/hypopnea index (AHI) was high in both groups, but was higher in the second group P<0.02. First treatment was always fixed CPAP in patients who preferred fixed CPAP, while it was either in the other subjects. CONCLUSIONS: Compliance to autoCPAP differs among OSAS patients. As long as factors predicting higher compliance to autoCPAP are not found, a trial with autoCPAP in patients poorly compliant to fixed CPAP may be warranted.

Benign fibrous histiocytoma of the small intestine in a cow.

A well circumscribed, firm nodule was found protruding from the duodenal wall of an adult cow at routine meat inspection. On the basis of morphological and immunophenotypic features, a diagnosis of benign fibrous histiocytoma (BFH) was established. Malignant fibrous histiocytoma has been reported previously in the cow, albeit rarely, but to the best of our knowledge this is the first recorded case of bovine intestinal BFH.

Hepatic biliary adenofibroma: a hitherto unrecognized tumor in equines. Report of a case.

Hepatic biliary cystadenoma is a well-delineated neoplasm in some domestic animals, especially in cats, but it has not been reported in equines. We report on a case of hepatic biliary tumor, incidentally found in a 10-year-old horse, with gross and microscopic features similar to those observed in biliary adenofibroma of humans. The tumor presented as a solid mass measuring 16 cm in diameter and histologically was composed of complex tubulocystic biliary components embedded in an abundant fibrotic stroma. We regarded this tumor as a morphological variant of biliary cystadenoma of domestic animals. Differential diagnoses from other hepatic biliary tumor-like and tumor lesions are provided.

Blood pressure responsiveness to obstructive events during sleep after chronic CPAP.

The aim of this study was to investigate whether chronic continuous positive airway pressure (CPAP) affects blood pressure (BP) responsiveness to obstructive events occurring on the first night of CPAP withdrawal in obstructive sleep apnoea (OSA) after chronic treatment. Thirteen male subjects with severe OSA underwent nocturnal polysomnography with beat-by-beat BP monitoring before treatment and after 4.9 +/- 3.4 months of home CPAP (mean daily use 5.1 +/- 1.7 h). Variations in oxyhaemoglobin saturation (deltaSa,O2), systolic (deltaPs), and diastolic (deltaPd) BP within nonrapid eye movement apnoeas and hypopnoeas were measured on a sample of pre- and post-treatment events. In addition, a pretreatment sample was selected for deltaSa,O2 to match post-treatment events. The higher the mean deltaSa,O2 was in the full pretreatment sample, the more deltaSa,O2, deltaPs and deltaPd were attenuated after treatment. Mean deltaPs decreased from 47.3 +/- 8.5 in the full pretreatment sample to 42.2 +/- 6.9 in the selected pretreatment sample, to 31.5 +/- 5.9 mmHg in the post-treatment sample. The post-treatment value differed significantly from both the pretreatment values. The corresponding values for mean deltaPd were 27.0 +/- 3.5, 24.0 +/- 3.1 and 19.6 +/- 3.7 mmHg, with all values differing significantly from each other. Chronic continuous positive airway pressure is followed by a decrease in apnoea/ hypopnoea-related blood pressure swings, possibly secondary to both reduced severity of event-related hypoxaemia and decreased responsiveness to obstructive events secondary to chronic prevention of nocturnal intermittent hypoxaemia.

Curative effects of recombinant human Interleukin-6 in DA rats with protracted relapsing experimental allergic encephalomyelitis.

We have studied the effects of treatment with recombinant human (rh)IL-6 on clinical, histological and immunological parameters of protracted relapsing (PR) experimental allergic encephalomyelitis (EAE) in DA rats. rhIL-6 (50 microg/rat subcutaneously/day) was given under three different regimens, as early prophylaxis, from 1 day prior to 14 days after immunization, in late prophylaxis, from day +7 until day 21 post-immunization (p.i.) and therapeutically to rats with clinical signs of EAE from day 14 to day 28 p.i. Although rhIL-6 failed to modulate the course of PR-EAE when administered as the early prophylactic regimen, it exerted clear-cut favourable effects on the course of the disease if was administered either as later prophylactic or as therapeutic treatment. Under these conditions, rhIL-6 accelerated recovery from EAE attacks and reduced/milded subsequent EAE episodes as compared to either PBS- or heat-inactivated rhIL-6-treated control rats. In agreement with this clinical effect, relative to PBS-treated rats, the animals injected with rhIL-6 exhibited lower numbers of MHC class II(+) and CD4(+) cells in their spinal cords. rhIL-6-treatment also profoundly modulated the endogenous cytokine network, the treated rats displaying increased numbers of spleen cells expressing mRNA transcripts of the anti-inflammatory cytokines IL-10 and TGF-beta along with simultaneously reduced numbers of mRNAs for TNF-alpha. In addition, upon ex vivo exposure to either myelin basic protein peptide 63-88 (MBP63-88) or to phytoaemagglutinin A, the numbers of IFN-gamma secreting splenocytes was also significantly reduced (ELISPOT analysis) in rhIL-6-treated rats as compared to PBS-treated controls.

Descending and ascending spinal cord evoked potentials from oesophago-vertebral electrical stimulation in normal awake man.

Electrical stimulation of the spinal cord at C7D1 evoked triphasic descending spinal cord evoked potentials (DSCEP) from an oesophago-vertebral recording at D8D8 or D1OD1O. Ascending SCEPs (ASCEP) larger and similar in shape were also observed when the orientation of the stimulating and recording dipoles was reversed. Both SCEPs are in part generated by descending and ascending synchronous excitation of neuronal volume-conducted spinal cord dipoles.

Evaluation of the POLYMESAM system in the diagnosis of obstructive sleep apnea syndrome.

The reliability of a POLYMESAM (PM) instrument in the detection of ventilatory disorders and in the diagnosis of obstructive sleep apnea syndrome (OSAS) was evaluated in 50 subjects suspected for OSAS, simultaneously studied by polysomnography (PSG) in a sleep laboratory. Recordings were analysed by separate scorers, blinded to the results of the paired recording. The number of central (Ac), obstructive (Ao) or mixed apneas (Am), of hypopneas (H), and the total number of ventilatory disorders (AH) per hour of time in bed (TIB) calculated on the two recordings were significantly correlated. Bland and Altman analysis showed a good agreement between AH/TIB, Ac/TIB, Am/TIB and mean AH duration; a lower Ao/TIB at PM was mirrored by a higher H/TIB. Forty-two subjects had OSAS according to an apnea/hypopnea index (AHI) > or = 10 at PSG. Due to low sleep efficiency, AH/TIB was substantially lower than AHI. However an AH/TIB > or = 5 at PM showed a sensitivity of 100% and a specificity of 71.4%, while an AH/TIB > or = 10 showed a sensitivity of 95.2% and a specificity of 100%. In conclusion, PM proved reliable for recognition of the characteristics of ventilatory disorders and for diagnosis of OSAS.

Influence of sampling interval on the evaluation of nocturnal blood pressure in subjects with and without obstructive sleep apnoea.

Blood pressure (BP) variability during sleep is high in obstructive sleep apnoea syndrome (OSAS). How BP sampling interval affects the estimate of mean nocturnal BP in OSAS and control subjects was investigated. Nine subjects with apnoea/hypopnoea index (AHI) <5 and 18 OSAS patients with AHI >30 underwent nocturnal polysomnography with beat-by-beat BP monitoring. Mean nocturnal BP was evaluated averaging: a) all systolic (Ps) and diastolic (Pd) BP values; b) Ps and Pd sampled every 5, 10, 15, 20, and 30 min. The sampling starting point was repeatedly shifted, and several mean BP estimates for each sampling interval were obtained. Differences (deltaPs and deltaPd) between means obtained by sampling BP and by averaging all BP values were calculated. In both groups deltaPs and deltaPd scatter increased as sampling interval increased; their variance was always higher in OSAS subjects (p<0.001). Over 95% of deltaPs and deltaPd were <5% of the beat-by-beat mean values at all sampling intervals in controls, but this occurred only at sampling intervals < or =10 min in OSAS subjects. To conclude, for each blood pressure sampling time, a larger number of inaccurate nocturnal mean blood pressure estimates are obtained in obstructive sleep apnoea syndrome than in control subjects. Obstructive sleep apnoea syndrome subjects require more frequent blood pressure measurements to obtain a similar accuracy in nocturnal blood pressure evaluation.

Diet therapy for rheumatoid arthritis. A controlled double-blind study of two different dietary regimens.

OBJECTIVE: To evaluate the effects of a diet therapy in patients with rheumatoid arthritis (RA). METHODS: Fifty RA patients entered a 24-week double-blind, randomised, controlled-study of two different dietary regimens (an experimental diet high in unsaturated fats, low in saturated fats with hypoallergenic foods vs. a control well-balanced diet). The primary end points of the study were 20% and 50% improvement in disease activity according to composite symptoms (Paulus index) of arthritis. Other end points were the other measures of disease activity at 12 and 24 weeks of diet treatment. RESULTS: The 2 groups were comparable at inclusion. Diet treatment was well tolerated and the rate of drop-outs was low. Percentage of patients with global 20 or 50% response didn't differ between experimental and control group after the 24-week of diet treatment. The experimental diet group did better for all the variables considered but only four variables (Ritchie's index, tender and swollen joints, and ESR) reached a statistical difference by multivariate analysis. Adjusting these data for weight variations, the number of tender joints (p=0.014) and ESR (p=0.025) were still statistically significant. CONCLUSIONS: Dietary manipulation, either by modifying food supplements or by reducing weight, may give some clinical benefit although no significant improvement can be observed assessing the results with a composite index.