Incidence and severity of SARS-CoV-2 infections in liver and kidney transplant recipients in the post-vaccination era: Real-life data from Denmark.

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 has been associated with a high risk of adverse outcomes in solid organ transplant (SOT) recipients in the pre-vaccination era. In this retrospective cohort study, we examined the incidence and severity of COVID-19 in kidney and liver transplant recipients in Denmark in the post-vaccination era, from December 27, 2020, to December 27, 2021. We included 1428 SOT recipients with 143 cases of first-positive SARS-CoV-2 PCR test. The cumulative incidence of first-positive SARS-CoV-2 PCR test 1 year after initiation of vaccination was 10.4% (95% CI: 8.8-12.0), and the incidence was higher in kidney than in liver transplant recipients (11.6% [95% CI: 9.4-13.8] vs. 7.4% [95% CI: 5.1-9.8], p = .009). After the first-positive SARS-CoV-2 PCR test, the hospitalization rate was 31.5% (95% CI: 23.9-39.1), and 30-day all-cause mortality was 3.7% (95% CI: 0.5-6.8). Hospitalization was lower in vaccinated than in unvaccinated SOT recipients (26.4% [95% CI: 18.1-34.6] vs. 48.5% [95% CI: 31.4-65.5], p = .011), as was mortality (1.8% [95% CI: 0.0-4.3] vs. 9.1% [95% CI: 0.0-18.9], p = .047). In conclusion, SOT recipients remain at high risk of adverse outcomes after SARS-CoV-2 infections, with a lower risk observed in vaccinated than in unvaccinated SOT recipients.

[SGLT2 inhibitorsfor treatment of chronic kidney disease without diabetes or heart failure].

This review summarises the current knowledge of electroconvulsive therapy (ECT) which is still the most potent and fast-acting antidepressant intervention. The modern procedure is safe when general precautions are taken. Cognitive side effects are transient in most patients, and concerns about side effects should not prevent relevant use. Due to the prognostic benefits of rapid remission, ECT should, in relevant patients, be considered early in the treatment course. Patients should be offered maintenance pharmacotherapy, and, in high-risk cases, tapering of the acute ECT course or maintenance ECT, in order to reduce the risk of relapse.

Decline in Antibody Concentration 6 Months After Two Doses of SARS-CoV-2 BNT162b2 Vaccine in Solid Organ Transplant Recipients and Healthy Controls.

Background: Previous studies have indicated inferior responses to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination in solid organ transplant (SOT) recipients. We examined the development of anti-receptor-binding domain (RBD) immunoglobulin G (IgG) after two doses of BNT162b2b in SOT recipients 6 months after vaccination and compared to that of immunocompetent controls. Methods: We measured anti-RBD IgG after two doses of BNT162b2 in 200 SOT recipients and 200 matched healthy controls up to 6 months after first vaccination. Anti-RBD IgG concentration and neutralizing capacity of antibodies were measured at first and second doses of BNT162b2 and 2 and 6 months after the first dose. T-cell responses were measured 6 months after the first dose. Results: In SOT recipients, geometric mean concentration (GMC) of anti-RBD IgG increased from first to second dose (1.14 AU/ml, 95% CI 1.08-1.24 to 11.97 AU/ml, 95% CI 7.73-18.77) and from second dose to 2 months (249.29 AU/ml, 95% CI 153.70-385.19). Six months after the first vaccine, anti-RBD IgG declined (55.85 AU/ml, 95% CI 36.95-83.33). At all time points, anti-RBD IgG was lower in SOT recipients than that in controls. Fewer SOT recipients than controls had a cellular response (13.1% vs. 59.4%, p < 0.001). Risk factors associated with humoral non-response included age [relative risk (RR) 1.23 per 10-year increase, 95% CI 1.11-1.35, p < 0.001], being within 1 year from transplantation (RR 1.55, 95% CI 1.30-1.85, p < 0.001), treatment with mycophenolate (RR 1.54, 95% CI 1.09-2.18, p = 0.015), treatment with corticosteroids (RR 1.45, 95% CI 1.10-1.90, p = 0.009), kidney transplantation (RR 1.70, 95% CI 1.25-2.30, p = 0.001), lung transplantation (RR 1.63, 95% CI 1.16-2.29, p = 0.005), and de novo non-skin cancer comorbidity (RR 1.52, 95% CI, 1.26-1.82, p < 0.001). Conclusion: Immune responses to BNT162b2 are inferior in SOT recipients compared to healthy controls, and studies aiming to determine the clinical impact of inferior vaccine responses are warranted.

An evaluation of live porcine simulation training for robotic surgery.

To assess the role of live porcine simulation in robotic surgical skills training. A qualitative and quantitative survey was conducted of participants of a live porcine robotic simulation course undertaken in a regional training centre. Data on participants' experience, robotic surgical ability, the educational impact and outcomes from the course were collected. Thirty-nine participants from four different countries completed the survey. Clinical experience varied; however, prior robotic surgical experience (median 0 cases, range 0-100) and technical ability were low. The perceived usefulness, effectiveness and realism of the training course were all highly scored. Participants rated the most useful course components as port placement and docking, basic robotic skills training and repair of a bladder injury. Training resulted in significant increases in technical ability (p < 0.0001). Following the course, 49% of participants continued to either train or perform robotic surgery. This survey demonstrates that live porcine simulation for robotic surgery is a highly valued, acceptable and feasible form of training. The majority of participants were relatively inexperienced but nonetheless significant improvements in technical ability were reported. The results of this survey support the use of live porcine training for robotic surgery.

Robotic versus laparoscopic urological surgery: incidence of reoperation and complications.

Objective: To report the introduction of minimum invasive surgery in Denmark with focus on the reoperation and complication rates. Materials and methods: Data were prospectively collected at the national UroLap database. The database was established in 2003 in Denmark to register all laparoscopic urological procedures as well as their peri- and post-operative outcomes. In the period from 2009-2014, 10,843 patients were registered with the database, of which 10,546 (97%) had a complete Clavien-Dindo score within the first 30 postoperative days. Results: The mean age of patients was 60.5 years (S.D. = 16.2), and 415 patients (4%) were under the age of 17 years. The male-to-female ratio was 4:1. At the end of 2010, 25% of surgeries used the robotic technique, but the frequency of robotic surgeries increased to 56% in 2014. No complications were reported in 74.6% of the urological procedures. The mortality rate was reported at only 0.27% of all patients. Patients who underwent a urological procedure performed by consultant urologists had a lower rate of complication compared to procedures performed by trainees (p = 0.03) but not staff doctors (p = 0.9). There were no significant differences in complication rates between staff doctors and trainee (p = 0.2). Conclusion: Robotic and laparoscopic urological procedures are associated with low serious complication rates. Postoperative complications were more common among surgeries performed by trainees. The robotic approach is associated with a shorter L.O.S. compared to the laparoscopic approach and linked to lower reoperation rates.

Laparoscopic and robotic nephroureterectomy: does lymphadenectomy have an impact on the clinical outcome?

PURPOSE: To evaluate the effect of lymphadenectomy (LND) in conjunction with nephroureterectomy on cancer-specific mortality (CSM) and overall survival (OS) for patients with muscle-invasive UTUC. METHODS: A retrospective, multicenter study of patients with UTUC, clinical stage N0M0, who underwent nephroureterectomy between January 2008 and December 2014 was conducted. Outcome measures were OS and CSM. RESULTS: In total, 298 patients underwent robot-assisted or laparoscopic radical nephroureterectomy with a final histological diagnosis of UTUC. LND was performed in 46 (15.4%). One hundred and seventy-two patients (62%) had non-muscle-invasive disease (NMID); 105 patients (38%) had muscle-invasive disease (MID). Median time of follow-up was 43.5 months (95% CI 36.0-47.2). For patients with MID, the 5-year cumulative incidence of all-cause mortality and CSM was 73.5% (95% CI 60.4-86.6) and 52.4% (95% CI 38.9-65.9), respectively (p < 0.0001). There was no significant difference in OS between patients with N1 and patients with N0 disease (p = 0.53). The 5-year OS rates were 30.5% (95% CI 6.6-54.4) and 25.7% (95% CI 10.9-40.5), respectively. This study is limited by its retrospective nature. There may also have been bias in the selection of patients undergoing LND. CONCLUSIONS: Five-year OS and CSM are comparable between patients with N1 and N0 MID. This evidence may support the use of the LND procedure in patients with muscle-invasive UTUC.

Robot-assisted surgery in a broader healthcare perspective: a difference-in-difference-based cost analysis of a national prostatectomy cohort.

OBJECTIVE: To estimate costs attributable to robot-assisted laparoscopic prostatectomy (RALP) as compared with open prostatectomy (OP) and laparoscopic prostatectomies (LP) in a National Health Service perspective. PATIENTS AND METHODS: Register-based cohort study of 4309 consecutive patients who underwent prostatectomy from 2006 to 2013 (2241 RALP, 1818 OP and 250 LP). Patients were followed from 12 months before to 12 months after prostatectomy with respect to service use in primary care (general practitioners, therapists, specialists etc) and hospitals (inpatient and outpatient activity related to prostatectomy and comorbidity). Tariffs of the activity-based remuneration system for primary care and the Diagnosis-Related Grouping case-mix system for hospital-based care were used to value service use. Costs attributable to RALP were estimated using a difference-in-difference analytical approach and adjusted for patient-level and hospital-level risk selection using multilevel regression. RESULTS: No significant effect of RALP on resource-use was observed except for a marginally lower use of primary care and fewer bed days as compared with OP (not LP). The overall cost consequence of RALP was estimated at an additional €2459 (95% CI 1377 to 3540, p=0.003) as compared with OP and an additional €3860 (95% CI 559 to 7160, p=0.031) as compared with LP, mainly due to higher cost intensity during the index admissions. CONCLUSIONS: In this study from the Danish context, the use of RALP generates a factor 1.3 additional cost when compared with OP and a factor 1.6 additional cost when compared with LP, on average, based on 12 months follow-up. The policy interpretation is that the use of robots for prostatectomy should be driven by clinical superiority and that formal effectiveness analysis is required to determine whether the current and eventual new purchasing of robot capacity is best used for prostatectomy.

Delayed diagnosis of adult indolent systemic mastocytosis.

Systemic mastocytosis (SM) is a rare, heterogeneous disorder characterized by infiltration and accumulation of mast cells within multiple organs, most commonly the skin. Given the rarity of the disease and the fact that many of its symptoms are shared by more common disorders, a diagnosis may be delayed or hindered. These patients have an elevated risk of developing potentially life-threatening anaphylactoid reactions, thus underscoring the importance of keeping SM in mind as a differential diagnosis when a patient presents with chronic, itchy skin lesions and a history of multiple allergic reactions to bites, drugs, and anesthesia. We present a case illustrating that features of SM common to many disorders may hinder or delay its diagnosis.

[Two cases of severe variceal haemorrhage from an ileal conduit].

Variceal haemorrhage from an ileal conduit is a rare but well-known complication to portal hypertension. Many treatments are described and a transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice if possible, because this addresses the underlying portal hypertension. We report two cases of haemorrhage from an ileal conduit, which illustrates that treatment must be individualized with attention to life expectancy, co-morbidities and degree of the portosystemic pressure gradient, but TIPS treatment has to be considered even if there is no history of liver disease.

Cyclosporine and Extracorporeal Photopheresis are Equipotent in Treating Severe Atopic Dermatitis: A Randomized Cross-Over Study Comparing Two Efficient Treatment Modalities.

BACKGROUND: Severe atopic dermatitis (AD) is a recurrent and debilitating disease often requiring systemic immunosuppressive treatment. The efficacy of cyclosporine A (CsA) is well proven but potential side effects are concerning. Several reports point at extracorporeal photopheresis (ECP) as an alternative treatment modality with few and mild side effects. However, no direct comparison between CsA and ECP in the treatment of AD has been performed so far. OBJECTIVES: To compare the efficacy of CsA (3 mg/kg/day) and ECP (administered two consecutive days twice a month) in a cohort of patients with severe AD. METHODS: A randomized cross-over study involving twenty patients with severe AD (SCORAD index 41-89) refractory to other treatments. The patients were allocated to a 4-month course of either of the two treatment modalities. Individual relapse periods (2-8 weeks) were interspersed before cross-over to the other treatment modality. Treatment efficacy was evaluated by SCORAD, PRURITUS (VAS-index 0-10), "overall global assessment" and serological biomarkers; sIL-2Rα, sE-selectin, eosinophilocytes, basophilocytes, and sIgE. RESULTS: 15 patients completed treatment. Both treatments lead to a marked and significant decrease in SCORAD and pruritus index. The average reduction of the SCORAD and pruritus index, respectively was a little higher for ECP treatment compared to CsA treatment; however, the differences did not reach statistical significance. The "overall global assessment" was significantly better in patients who underwent ECP therapy as compared to CsA treatment. None of the biomarkers showed significant changes after either treatment when compared to the initial values. CONCLUSION: ECP administered on two consecutive days twice a month to patients with severe AD has similar potency as CsA administered daily in a moderate dose. ECP is a treatment alternative in patients with severe AD that do not tolerate or are refractory to conventional immunosuppressants.

Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants - South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres). OBJECTIVES: To establish the feasibility and acceptability of a centralized, simulation-based training-programme. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills. MATERIALS AND METHODS: For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales. RESULTS: In total 33, three specialist registrars of different grades and five urological nurses participated in the present study. Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized. A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills. CONCLUSIONS: A centralized simulation programme that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

One-week oral challenge with penicillin in diagnosis of penicillin allergy.

Many patients experience reactions during penicillin treatment. The diagnosis may be difficult and is mainly based on short-term tests. The European Network for Drug Allergy (ENDA) guidelines proposed for diagnosing penicillin allergy do not include long-term challenge. In this study a total of 405 patients were evaluated. The ENDA guidelines were extended, to include a 7-day oral treatment (p.o.7) with penicillin for all patients who were negative in the ENDA programme. Among the 405 patients; 85 had an immediate reaction to penicillin, and a further 13 reacted during p.o.7. Among the 307 patients with a negative outcome, 88 had a case history of reaction to other ß-lactam antibiotics and were subsequently tested with the culprit drug. Thirteen patients had a positive outcome: 3 on single-dose challenge and 10 during p.o.7. The extended penicillin diagnostic work-up was positive in 111 patients, 30.0% showed immediate reactions and 5.7% reacted during p.o.7. Approximately 20% of all patients with positive outcome during penicillin challenge are detected by adding p.o.7 with penicillin to the original ENDA guidelines.

Scarless single-port laparoscopic pelvic kidney nephrectomy.

INTRODUCTION: We report the first pelvic kidney removal through the umbilicus using a scarless pure single-port technique in a young woman. PATIENTS AND METHODS: A 27-year-old woman presented with uro-sepsis and acute renal failure secondary to a dilated, chronically infected, nonfunctioning left-sided pelvic kidney with ureteropelvic obstruction causing an obstruction to the right kidney. The acute episode was managed with bilateral ureteric stents and antibiotics. Definitive treatment involved removal of the diseased pelvic kidney through the umbilicus via a single-port access device (TriPor™; Olympus). A curved tissue grasper and extralong bariatric suction device were used along with standard straight laparoscopic instruments. In addition, a 10-mm flexible-tip video laparoendoscope (HD EndoEYE LTF-VH™; Olympus) and a robotic camera holder (FreeHand™; Prosurgics) were used to reduce external instrument clash. RESULTS: The procedure was technically successful leaving the patient with a scarless abdomen. The operative time was 185 minutes, blood loss 100 mL, and length of stay 48 hours. There were no complications. CONCLUSION: Scarless transumbilical pelvic nephrectomy is technically feasible. The first reported clinical experience is discussed.

[Organisation of basic training in laparoscopic surgery]. / Organisering af basal uddannelse i laparoskopisk kirurgi.

INTRODUCTION: Training, development and implementation of minimally invasive surgery is resource-demanding. The new Danish specialist training programme combined with shorter employment periods and working hours have increased the need for a more efficient education, training and certification of surgery, gynaecology and urology trainees. MATERIAL AND METHODS: A total of 106 trainees who were non-specialised doctors from a region in Denmark underwent theoretical as well as practical specialised training in laparoscopy in the period 2006-2008. The training had several modules of which the two first are described. The training and evaluation methods used were objective, structured clinical examination (OSCE-test) and objective skill assessments tests (OSATS-test). RESULTS: Among the 108 trainees, a total of 80 physicians passed. On module 1, the distribution of participants with regards to speciality was: surgery 47 physicians, urology 14 physicians and gynaecology 45 physicians. Six physicians were not certified. We have registered OSATS-scores for 64 participants with a median score of 3.0 (range 1-4.4). To pass, the multiple choice test participants needed to answer 66% of the questions correctly. Below this level were 20 participants out of 57 (35%) on module 1 and 32 out of 60 (53%) on module 2. CONCLUSION: Thanks to political attention and sufficient financing a centre without physical premises has been established. It has been possible to offer training to young surgeons during their first year with both benchmark training and live operations in animal models. The concept may also be used by the trainee as guidance when making education and career choices.

Heritable features of the optic disc: a novel twin method for determining genetic significance.

PURPOSE: Numerous genetic diseases and environmental stimuli affect optic nerve morphology. The purpose of this study was to identify the principal heritable components of visible optic nerve head structures in a population-based sample of twins. METHODS: Fifteen optic nerve specialists viewed stereoscopic optic nerve head photographs (Stereo Viewer-II; Pentax Corp., Tokyo, Japan) from 50 randomly selected monozygotic or dizygotic twin pairs. Before viewing, each expert was questioned about which optic nerve head traits they believed were inherited. After viewing a standardized teaching set, the experts indicated which twin pairs they thought were monozygotic. Participants were then questioned about how their decisions were reached. A rank-ordered Rasch analysis was used to determine the relative weighting and value applied to specific optic nerve head traits. RESULTS: The proportion of twin pairs for which zygosity was correctly identified ranged from 74% to 90% (median, 82%) across the panel. Experts who correctly identified the zygosity in more than 85% of cases placed most weighting on shape and size of the optic disc and cup, whereas experts with the lowest scores placed greater weighting on the optic nerve head vasculature in reaching their decisions. CONCLUSIONS: In determining the genetic components of the optic nerve head, the results of this study suggest that the shape and size of the optic disc and cup are more heritable and should receive a greater priority for quantification than should vascular features.

Screening for glaucomatous disc changes prior to diagnosis of glaucoma in myocilin pedigrees.

OBJECTIVE: To investigate whether structural differences of the optic nerve head are evident in young people who do not have manifest glaucoma but are known to carry myocilin mutations. METHODS: A case-control design was adopted. Subjects from Australian pedigrees known to have either the Gln368STOP myocilin mutation (cutoff age, <40 years) or the Thr377Met myocilin mutation (cutoff age, <30 years) were examined for signs of glaucoma. Stereoscopic disc photographs were digitalized. Analysis of the optic disc area, optic cup area, and neuroretinal rim area was performed using digital stereoscopy with a Z-screen. Mutation analysis was conducted using direct sequencing. The t test, corrected for multiple comparison testing, was used in analysis. RESULTS: A total of 29 myocilin mutation-carrying (case) and 33 mutation-free (control) individuals were reviewed. The mean +/- SD ages were 19.9 +/- 9.0 and 22.1 +/- 9.5 years in the mutation and mutation-free groups, respectively (P = .35). There was no significant difference in intraocular pressure between mutation carriers and noncarriers (P = .44). There were no statistically significant differences in the mean disc, neuroretinal rim, and cup areas between the groups. The mean +/- SD neuroretinal rim area was 1.24 +/- 0.24 mm(2) in the noncarrier group and 1.25 +/- 0.23 mm(2) in the mutation group (P = .46). No notch, nerve fiber layer defect, or neuroretinal rim hemorrhage was noted in any eye examined. CONCLUSIONS: Although confounded by penetrance and expressivity, no quantified structural difference in the optic nerve head was observed in individuals who had a myocilin mutation prior to the diagnosis of glaucoma.

Retroperitoneal dismembered pyeloplasty: initial experiences.

AIM: To review the results of our first 40 cases of retroperitoneal dismembered pyeloplasty and to compare them with series of open and other minimally invasive treatments of pelviureteric junction (PUJ) obstruction. Also to compare our first 20 cases with the second 20 cases to see if there was an improvement in results with experience. METHODS: A retrospective review of the first 40 laparoscopic pyeloplasties performed by a single lead surgeon at two institutions was performed. The diagnosis of PUJ obstruction was confirmed with an intravenous urogram as well as a renogram prior to surgery. A retroperitoneal, dismembered pyeloplasty was routinely performed with three or four ports. All patients were followed up with an intravenous urogram, renogram and review of symptoms at 4 months and annual renogram after that. RESULTS: Average operation time was 236 min and this appeared to decrease with experience. Two cases had to be converted to open operations. The mean hospital stay was 3.4 days. Out of the 40 patients, 34 have had successful laparoscopic operations with total symptomatic relief as well as radiologically proven deobstruction. There were four major complications with 3 patients going on to have redo open pyeloplasty operations. There were seven minor complications. CONCLUSIONS: In our experience, retroperitoneal dismembered pyeloplasty is an effective and safe means of treating PUJ obstruction. Our results seem to be comparable with series of open pyeloplasty and other laparoscopic series and are better than some other minimally invasive techniques.

Positional anatomy of vessels that may be damaged at laparoscopy: new access criteria based on CT and ultrasonography to avoid vascular injury.

BACKGROUND AND PURPOSE: To study the relations of major blood vessels (aortoiliac bifurcation and iliocaval confluence) and the inferior epigastric arteries to the umbilicus and the anterior superior iliac spine (ASIS) planes and to apply this information to define ideal, anatomically based locations for primary and secondary laparoscopic port insertions to minimize vascular injuries. MATERIALS AND METHODS: Two hundred randomly selected postcontrast CT images of the abdomen and pelvis were assessed by two radiologists. The position of the umbilicus (mobile point), ASIS (fixed point), and relations with the great vessels were measured. The angle of the umbilicus with the aortic bifurcation, theta (theta), was calculated using trigonometric principles. The position and course of the inferior epigastric arteries (IEA) was analyzed in 103 patients with color Doppler ultrasonography. RESULTS: The median distance of the aortoiliac bifurcation was 8 mm (interquartile range [IQR] 28.8 mm] and that of the iliocaval venous confluence 25 mm (IQR 32 mm) below the umbilicus. The aorta divided 48 mm (IQR 16 mm) and the iliac veins joined 33 mm (IQR 9 mm) above the ASIS plane. The angle of the umbilicus to the aortoiliac bifurcation in the sagittal plane had a range of 14 degrees to 34 degrees with a median of 21.6 degrees . The median distance from the right IEA to the midline at the umbilicus was 4.75 cm (IQR 0.7 cm), and the same distance in the ASIS plane was 4.8 cm (IQR 0.7 cm). The distance of the IEA to the midline did not exceed 6 cm in any patient on either side or in either plane. CONCLUSION: The position of the umbilicus should not be relied on for access planning. The relation between the level of the ASIS and the aortic bifurcation is more consistent. The ideal primary port entry (or Veress needle site) is at the ASIS plane in the midline, and the ideal lateral port entry is in the same plane >6 cm from the midline. If the umbilicus is to be used, a Hasson insertion is desirable, but if a Veress needle is used at the umbilicus, an angle of 45 degrees in the sagittal plane should be used.

Prostate tissue and leukocyte levels of n-3 polyunsaturated fatty acids in men with benign prostate hyperplasia or prostate cancer.

OBJECTIVE: To compare the levels of n-3 polyunsaturated fatty acids (PUFAs) in leukocytes and prostate tissue in men with prostate cancer or benign prostatic hyperplasia (BPH), as dietary intake of n-3 PUFAs has been linked to the risk of prostate cancer; the prostate-specific antigen (PSA) level was also compared to prostate tissue levels of n-3 PUFAs. PATIENTS AND METHODS: Prostate tissue was obtained and leukocytes isolated from 20 men with prostate cancer and 35 with BPH. The n-3 PUFAs alpha-linolenic acid (ALA), eicosapentanoic acid (EPA) and docosahexaenoic acid (DHA) were measured in prostate tissue and in peripheral blood leukocytes using gas chromatography. PSA levels were measured in all of the men. RESULTS: There was a strong positive correlation between EPA and DHA in leukocytes and in prostate tissue (EPA: r = 0.80, DHA: r = 0.53, both P < 0.001) in all the men, whereas there was no association between the content of ALA in leukocytes and in prostate tissue (r = -0.15). Men with BPH had similar levels of ALA in leukocytes and in prostate tissue, but men with prostate cancer had more ALA in prostate tissue than in leukocytes. The PSA level was significantly positively correlated with ALA level in prostate tissue (r = 0.42, P < 0.01) but there was no significant correlation between PSA level and EPA and DHA levels. There were no significant correlations between PSA level and n-3 PUFA levels in leukocytes. CONCLUSION: Dietary intake of the marine n-3 PUFAs reflected in EPA and DHA levels in leukocytes are also reflected in EPA and DHA levels in prostate tissue in men with and without prostate cancer. However, there is a discrepancy between the levels of ALA in leukocytes and in prostate tissue, with higher levels in men with prostate cancer. This is in accordance with the strong positive association between PSA and ALA levels in prostate tissue. This study therefore does not support the hypothesis that intake of marine n-3 PUFAs might protect against prostate cancer, but lends support to the deleterious role of ALA in the development of prostate cancer.

Laparoscopic management of complicated urachal remnants.

OBJECTIVE: To report our experience with a laparoscopic approach to managing symptomatic urachal anomalies. PATIENTS AND METHODS: Five patients (median age 19 years, range 2-43) had a laparoscopic excision of a complicated urachal remnant between 2001 and 2004. Three ports were routinely used, although their positioning varied as our technique developed with experience. The urachal remnant was dissected from the umbilicus to the bladder dome and then removed intact. RESULTS: All five operations had no serious immediate complications and minimal blood loss. One patient developed a small peri-umbilical haematoma after surgery and another had a persistent umbilical discharge at follow-up, and required open excision of residual remnant tissue. CONCLUSIONS: The laparoscopic approach appears to be a safe and effective alternative to open surgery for this condition. Despite the slight risk of incomplete excision, the reduced morbidity of this procedure and better cosmetic result would appear advantageous.