Surgical treatment of benign prostatic hyperplasia: Thulium enucleation versus single-port transvesical robotic simple prostatectomy.

Objective: The objective of this work is to compare our outcomes using thulium laser enucleation of prostate (ThuLEP) to the single-port robot-assisted simple prostatectomy (SP RASP) in the surgical management of benign prostatic hyperplasia (BPH). Methods: A retrospective cohort study was conducted from January 2017 through December 2021 of men who underwent SP RASP and ThuLEP performed by a single surgeon with an enucleation experience of >300 cases and extensive robotic experience. The primary outcome was changed in International Prostate Symptom Score (IPSS) postoperatively. Secondary outcomes were operative time, length of stay (LOS), change in post-void residuals (PVR), de novo stress- or urge-urinary incontinence (SUI, UUI), and rate of complications. Results: One hundred two patients underwent surgery during the study period: 33 RASP and 69 ThuLEP. There was no difference in preoperative characteristics, including age and body mass index, between both groups. Changes in IPSS scores postoperatively were not significant between SP RASP versus ThuLEP (-17 vs. -14, p = 0.2956). SP RASP had a longer operative time (180 vs. 90 min, p < 0.0001). There was no difference in LOS (0 vs. 0 days, p = 0.2904). There was no difference in change in PVR (-96 vs. -91 mL, p = 0.8504). SP RASP patients had significantly less postoperative SUI than ThuLEP (0 vs. 13 patients, p = 0.0083), while there was no difference in UUI between both groups (4 vs. 2 patients, p = 0.0843). There was no difference in 30-day complication rate (21.2% vs. 21.7%, p = 0.9517), although there were three ThuLEP patients with Clavien-Dindo Class III or higher complication. Conclusions: There was no difference in change in IPSS scores between the two groups. ThuLEP is associated with shorter postoperative catheter days and decreased operative times. Hospital LOS was equivalent. SP RASP demonstrates significantly improved continence rates. Though SP RASP is within the initial learning curve at our institution, early results demonstrate the role for this modality alongside ThuLEP in the treatment of large gland BPH.

Extramedullary Waldenström Macroglobulinemia Presenting as a Subcutaneous Penile Mass.

Primary penile malignancy is a rare occurrence in the United States, with squamous carcinoma being the most common aetiology. Non-squamous penile cancers are scarcely reported in the literature. We present a unique case of a 65-year-old male with a history of Waldenström macroglobulinemia (WM) previously in remission complaining of a painless subcutaneous bump on the base of the penis. Biopsy with histological and immunohistochemical analysis confirmed the recurrence of WM. This novel case illustrates an unusual presentation of the disease after being successfully managed with chemotherapy and immunotherapy in an asymptomatic individual. There is only another reported case in the literature of a patient with a similar presentation. We highlight the clinical features and presentation of this condition, including a consensus for the approach and management of non-Hodgkin's lymphomas of the penis.

Is preoperative genicular radiofrequency ablation effective for reducing pain following total knee arthroplasty? A pilot randomized clinical trial.

BACKGROUND AND OBJECTIVE: Although total knee arthroplasty (TKA) is an effective treatment for severe knee osteoarthritis (OA), a subset of patients experience significant postoperative pain and dissatisfaction. Several clinical trials support the analgesic benefits of genicular nerve radiofrequency ablation (GN-RFA) for non-operative knee OA, but only one prior trial has examined the effects of this intervention given preoperatively on postoperative outcomes following TKA, showing no analgesic benefit of cooled GN-RFA. The current study evaluated whether conventional thermal GN-RFA performed preoperatively resulted in significant improvements in pain and function following TKA. METHODS: This was a single-center, prospective, randomized, sham-controlled, double-blinded pilot trial in which patients received either conventional GN-RFA (n=30) or sham (n=30) between 2 and 4 weeks prior to their TKA. Baseline measures were obtained preprocedurally on the day of intervention, with follow-up outcomes obtained preoperatively on the day of surgery, and at 2 and 6 weeks postoperatively. RESULTS: Patients receiving GN-RFA showed no significant improvements relative to sham controls in the primary outcome, pain intensity at rest at 6-week follow-up. Secondary outcomes, including pain with ambulation and physical function, also showed no significant differences between groups at any follow-up assessment. CONCLUSIONS: Conventional GN-RFA of the superior lateral, superior medial, and inferior medial genicular nerves when performed prior to TKA did not provide clinically significant pain relief or improvement in functional status at 2 or 6 weeks postoperatively. TRIAL REGISTRATION NUMBER: NCT02947321.

Attenuation of the Induction of TLRs 2 and 4 Mitigates Inflammation and Promotes Neurological Recovery After Focal Cerebral Ischemia.

The intense inflammatory response triggered in the brain after focal cerebral ischemia is detrimental. Recently, we showed that the suppression of toll-like receptors (TLRs) 2 and 4 attenuates infarct size and reduces the expression of pro-inflammatory cytokines in the ischemic brain. In this study, we further examined the effect of unsuppressed induction of TLRs 2 and 4 on the expression of its downstream signaling molecules and pro-inflammatory cytokines 1 week after reperfusion. The primary purpose of this study was to investigate the effect of simultaneous knockdown of TLRs 2 and 4 on M1/M2 microglial polarization dynamics and post-stroke neurological deficits and the recovery. Transient focal cerebral ischemia was induced in young adult male Sprague-Dawley rats by the middle cerebral artery occlusion (MCAO) procedure using a monofilament suture. Appropriate cohorts of rats were treated with a nanoparticle formulation of TLR2shRNA and TLR4shRNA (T2sh+T4sh) expressing plasmids (1 mg/kg each of T2sh and T4sh) or scrambled sequence inserted vector (vehicle control) expressing plasmids (2 mg/kg) intravenously via tail vein immediately after reperfusion. Animals from various cohorts were euthanized during reperfusion, and the ischemic brain tissue was isolated and utilized for PCR followed by agarose gel electrophoresis, real-time PCR, immunoblot, and immunofluorescence analysis. Appropriate groups were subjected to a battery of standard neurological tests at regular intervals until 14 days after reperfusion. The increased expression of both TLRs 2 and 4 and their downstream signaling molecules including the pro-inflammatory cytokines was observed even at 1-week after reperfusion. T2sh+T4sh treatment immediately after reperfusion attenuated the post-ischemic inflammation, preserved the motor function, and promoted recovery of the sensory and motor functions. We conclude that the post-ischemic induction of TLRs 2 and 4 persists for at least 7 days after reperfusion, contributes to the severity of acute inflammation, and impedes neurological recovery. Unlike previous studies in TLRs 2 or 4 knockout models, results of this study in a pharmacologically relevant preclinical rodent stroke model have translational significance.

A Case Report Describing Three Cases of Challenging or Failed Intubation after Cervical Spine Surgery: A Peril of Early Extubation.

Postoperative airway complications can be a common, yet perhaps underappreciated, complication in patients undergoing cervical spine surgery. Presented here are three cases in which patients experienced postoperative airway compromise, resulting in difficulty establishing a secure airway following cervical spine operations. Establishing factors that contribute to airway complications after cervical spine surgery can aid in early identification of high-risk patients to create an appropriate airway management strategy. Ultimately, the frequency of airway difficulty after removal of the endotracheal tube in patients undergoing cervical spine surgery should not be taken lightly.

Self-reported cumulative medical opioid exposure and subjective responses on first use of opioids predict analgesic and subjective responses to placebo-controlled opioid administration.

BACKGROUND AND OBJECTIVES: To expand the evidence base needed to enable personalized pain medicine, we evaluated whether self-reported cumulative exposure to medical opioids and subjective responses on first opioid use predicted responses to placebo-controlled opioid administration. METHODS: In study 1, a survey assessing cumulative medical opioid exposure and subjective responses on first opioid use was created (History of Opioid Medical Exposure (HOME)) and psychometric features documented in a general sample of 307 working adults. In study 2, 49 patients with chronic low back pain completed the HOME and subsequently rated back pain intensity and subjective opioid effects four times after receiving saline placebo or intravenous morphine (four incremental doses) in two separate double-blinded laboratory sessions. Placebo-controlled morphine effects were derived for all outcomes. RESULTS: Two HOME subscales were supported: cumulative opioid exposure and euphoric response, both demonstrating high test-retest reliability (Intraclass Correlation Coefficients > 0.93) and adequate internal consistency (Revelle's Omega Total = 0.73-0.77). In study 2, higher cumulative opioid exposure scores were associated with significantly greater morphine-related reductions in back pain intensity (p=0.02), but not with subjective drug effects. Higher euphoric response subscale scores were associated with significantly lower overall perceived morphine effect (p=0.003), less sedation (p=0.04), greater euphoria (p=0.03) and greater desire to take morphine again (p=0.02). DISCUSSION: Self-reports of past exposure and responses to medical opioid analgesics may have utility for predicting subsequent analgesic responses and subjective effects. Further research is needed to establish the potential clinical and research utility of the HOME. TRIAL REGISTRATION NUMBER: NCT02469077.

Evaluation of the safety of high-frequency chest wall oscillation (HFCWO) therapy in blunt thoracic trauma patients.

BACKGROUND: Airway clearance is frequently needed by patients suffering from blunt chest wall trauma. High Frequency Chest Wall Oscillation (HFCWO) has been shown to be effective in helping to clear secretions from the lungs of patients with cystic fibrosis, bronchiectasis, asthma, primary ciliary dyskinesia, emphysema, COPD, and many others. Chest wall trauma patients are at increased risk for development of pulmonary complications related to airway clearance. These patients frequently have chest tubes, drains, catheters, etc. which could become dislodged during HFCWO. This prospective observational study was conducted to determine if HFCWO treatment, as provided by The Vesttrade mark Airway Clearance System (Hill-Rom, Saint Paul, MN), was safe and well tolerated by these patients. METHODS: Twenty-five blunt thoracic trauma patients were entered into the study. These patients were consented. Each patient was prescribed 2, 15 minute HFCWO treatments per day using The Vest(R) Airway Clearance System (Hill-Rom, Inc., St Paul, MN). The Vest(R) system was set to a frequency of 10-12 Hz and a pressure of 2-3 (arbitrary unit). Physiological parameters were measured before, during, and after treatment. Patients were free to refuse or terminate a treatment early for any reason. RESULTS: No chest tubes, lines, drains or catheters were dislodged as a result of treatment. One patient with flail chest had a chest tube placed after one treatment due to increasing serous effusion. No treatments were missed and continued without further incident. Post treatment survey showed 76% experienced mild or no pain and more productive cough. Thirty days after discharge there were no deaths or hospital re-admissions. CONCLUSION: This study suggests that HFCWO treatment is safe for trauma patients with lung and chest wall injuries. These findings support further work to demonstrate the airway clearance benefits of HFCWO treatment.

Renal interstitial Ca2+ during sodium loading of normotensive and Dahl-salt hypertensive rats.

It is now established that cells in many tissues including renal epithelial cells and perivascular sensory nerves have mechanisms that monitor and respond to the concentration of Ca2+ in the interstitial compartment [Ca2+(ISF)]. We tested the hypothesis that high Na+ intake alters renal [Ca2+(ISF)] and that the response is altered in salt-sensitive hypertensive versus normotensive rats. Male Wistar (W), Dahl salt-resistant (DR), and Dahl salt-sensitive (DS) rats were fed diets containing 0.45% or 8% NaCl for 7 days beginning at 8 to 10 weeks of age. Systolic blood pressure (BP) was measured before and at the end of the 7-day period. During the last 12 h the animals were placed in metabolic cages for urine collection. They were then anesthetized and renal [Ca2+(ISF)] was determined using in situ microdialysis. Feeding 8% NaCl caused a significant increase in systolic BP only in DS. The 8% NaCl also caused a significant increase in renal urinary Na+ excretion in all groups, had no effect on renal Ca2+ excretion in W or DS and significantly increased urinary Ca2+ excretion in DR. When fed 0.45% NaCl, renal [Ca2+(ISF)] was lower in W and DR compared with DS. Feeding 8% NaCl significantly increased [Ca(ISF)] in W, had no effect on this parameter in DR, and significantly decreased [Ca2+(ISF)] in DS ([Ca2+(ISF)] for DS on 0.45% NaCl = 1.89 +/- 0.15 v 8% NaCl = 1.08 +/- 0.07 mmol/L, n = 6 to 12, P <.05). These results indicate that Na+ loading significantly alters renal [Ca2+(ISF)]; that the response of DS is disturbed relative to controls, and are consistent with the hypothesis that Na+ loading can alter cell function by modulating [Ca2+(ISF)].