Isoflurane Increases Tolerance to Renal Ischemia Reperfusion Injury Compared to Propofol: An Experimental Study in Pigs.

Purpose: To compare two clinically relevant anesthetic agents, i.e., isoflurane versus propofol with respect to protection of the kidney in a porcine renal ischemia reperfusion model. Materials and Methods: 14 hybrid pigs were randomized to anesthesia with either isoflurane or propofol prior to laparoscopic surgery. Following anesthesia, the left kidney hilum was clamped for 60 min and the right kidney removed. After 48 h of reperfusion, urine was sampled for analysis of neutrophil gelatinase-associated lipocalin (NGAL), albumin, and creatinine. The left kidney was harvested for histologic scoring of injury. Results: Histologic examination of renal injury revealed a statistically significant difference in favor of isoflurane on denuded basement membrane score (isoflurane group 1.58 ± 0.38 vs. propofol 2.42 ± 0.80, p = .026). Median (25-75 percentile) urinary albumin 3.4 g/L (2.25-7.48) vs. 8.9 g/L (3.73-13.8), (p = .041) and urinary albumin/creatinine ratio 1.17 (0.76-1.82) vs. 1.76 (1.63-5.99), (p = .026) were both significantly lower in the isoflurane group. Median (25-75 percentile) urinary NGAL was 167 (51-215) pg/ml in the isoflurane group compared with 362 (149-508) pg/ml in the propofol group (p = .093). Conclusion: Isoflurane increases tolerance to renal ischemia reperfusion injury compared to propofol in this model.

Improvement in early continence after introduction of periurethral suspension stitch in robotic prostatectomy.

Early urinary incontinence remains a major source of morbidity for patients undergoing robotic prostatectomy. The purpose of the study was to determine whether the introduction of a suspension stitch would improve early urinary continence rates in patients undergoing robotic prostatectomy for localized prostate cancer at our department. We retrospectively reviewed patients undergoing robotic prostatectomy with either suspension (n = 119) or figure-of-eight (n = 48) stitching of the dorsal venous complex. The patients submitted EPIC-26 questionnaires before surgery and after 3 and 18 months, respectively. Logistic regression analysis was run to determine the effect of the suspension stitch, nerve-sparing, posterior reconstruction, prostate volume, age and body mass index on early continence rate. The odds ratio of experiencing urinary leaks was 2.1 times higher (95% CI 1.0-4.3) in the figure-of-eight stitch group compared to the suspension stitch group 3 months after surgery (p < 0.05). The early urinary continence rate was 61.3% in the suspension stitch group compared to 35.4% in the figure-of-eight stitch group (p < 0.005). There were no differences between the groups 18 months post-prostatectomy (90.7% in the suspension stitch group versus 81.4% in the non-suspension stitch group, p = 0.1). Ordinal regression analysis identified the suspension stitch, bilateral nerve-sparing and body mass index as independent predictors of urinary continence at 3 months. The association between urinary continence and either unilateral nerve-sparing, posterior reconstruction, prostate volume or age did not reach statistical significance. Our results suggest that the suspension stitch improved early urinary continence following robotic prostatectomy.

Strategies to improve quality of life in bladder cancer patients.

Bladder cancer is a heterogeneous disease that includes both tumors with low risk of dissemination as well as highly malignant tumors with a considerable potential to metastasize. The patient's quality of life is closely related to the management of the disease. The challenge for the urologist is to acknowledge the malignant potential of the cancer and to adjust the approach to the patient accordingly. Patients with low-risk bladder cancer should avoid an exaggerated follow-up, but on the other hand high-risk patients must be sufficiently surveyed to secure that definitive surgical treatment is performed before it's too late. When the decision to perform a cystectomy has been made, it is crucial that the patient understands the consequences of the surgery as well as the possible options for urinary reconstruction. This review focuses on aspects of bladder cancer management that we believe are vital for the quality of life of these patients.

Mitral valve surgery--a Scandinavian perspective.

During the last three decades, the most prevalent surgical mitral valve disease in Scandinavia has changed from the sequelae of rheumatic fever to the mitral valve pathologies related to ischemic heart disease. Also, the total number of patients in need of a mitral valve procedure is increasing. For several of the patients with ischemic mitral valve disease, the natural prognosis of their disease is dismal. However, there are several uncertainties as to whether or not a surgical procedure can improve the life expectancies of these patients. Also, the procedures of choice for patients with ischemia related "functional mitral valve disease" is a long standing controversy. In this issue of "Scandinavian Cardiovascular Journal" we present the rationale and protocol for the "MoMIC" trial, a randomized multicenter study aiming to clarify whether revascularization alone or a combined revascularization and mitral valve annuloplasty is the treatment of choice for patients with ischemia related moderate mitral regurgitation.

Utilization and outcome of coronary revascularization and valve procedures in acute heart failure--an evaluation based on the classification from the European Society of Cardiology.

Early invasive treatments in patients with acute heart failure (AHF) are critical components to improve outcome. We aimed to establish if such treatments were applied according to existing guidelines and also to assess the subsequent mortality in the complete AHF population. All patients with AHF admitted to the intensive care unit/coronary care unit during the years 2003-2004 (n=302) were retrospectively reviewed and classified according to the European Society of Cardiology. Invasive revascularization was applied more frequently in patients with cardiogenic shock following acute coronary syndromes (78%, n=40) than in less severe AHF (58%, n=62, P<0.05). Only 8% (n=4) of eligible patients with acute coronary syndromes and cardiogenic shock were treated non-invasively. Valvular dysfunction was a precipitating factor for AHF in 15% (n=38). Acute mitral regurgitation was treated surgically exclusively in patients with mechanical defects. In-hospital mortality rates for less severe AHF was 12%, cardiogenic shock 46% and postcardiotomy HF 32%. Invasively treated patients had lower in-hospital mortality in both cardiogenic shock (35% vs. 70%, P=0.006) and less severe AHF (6% vs.17%, P=0.042). The study revealed an appropriate use of invasive revascularization. The high mortality in patients with severe AHF indicates that more effective treatment options are needed in eligible patients.

How many acute heart failure patients need a ventricular assist device?

OBJECTIVES: The most severe forms of acute heart failure have a dismal prognosis despite modern invasive treatment. For some of these patients, improved outcome must relay on early institution of ventricular assist devices (VAD). We aimed to estimate the potential VAD need in acute heart failure. DESIGN: All patients admitted to the ICU or CCU for acute heart failure (AHF) in 2003/04 (n=302) were reviewed. Non-survivors with severe acute heart failure, i.e. cardiogenic shock and postcardiotomy HF, were individually reviewed to assess eligibility for VAD-treatment. RESULTS: Cardiogenic shock and postcardiotomy HF was present in 23% (n=69) and 19% (n=57) of the AHF patients. Overall in hospital mortality in these groups was 38% (n=48). Of these, 15 were less than 75 years of age, without serious comorbidities and thus deemed to be potential candidates for VAD-treatment. CONCLUSION: This survey indicates that 12% of patients with severe acute heart failure are potential candidates for VAD-treatment. Extending these figures to a national level, indicate that approximately 70 patients per year could be candidates for short-term VAD-treatment in Norway.