Head-to-head comparison of retropubic, perineal and laparoscopic radical prostatectomy

OBJECTIVE: As more patients are diagnosed with prostate cancer at an early stage, it is becoming increasingly important to refine the technique of surgical excision. For this purpose we have generated objective data comparing three different surgical approaches used by three experienced surgeons. METHODS: We prospectively compared three contemporary personal series of 50 consecutive radical prostatectomy (RP) patients. The health-related quality of life was evaluated preoperatively and in months 1, 3, 6, 12 and 24. RESULTS: Considering in turn the patients undergoing retropubic, perineal and laparoscopic RP, the median procedure time was 2 h and 27 min, 1 h and 50 min and 4 h, with a transfusion rate of 2, 0 and 8%, respectively. In the perineal group there were more wound infections. Median catheter drainage was 7, 10 and 7 days and zero, 13 and one patients needed reinsertion of a catheter. Early continence varied considerably, with 57.4, 11.4 and 6.3% of patients pad-free after 1 month, but there were no differences in social continence (zero or one pad) with 97.8, 97.8 and 91.9% after 2 years. The Litwin score for incontinence (preoperative minus postoperative) was -24, -41 and -63% after 1 month and -13, +3 and -29% after 2 years. Twenty-nine, five and 15 patients had a preoperative five-item version of International Index of Erectile Function (IIEF-5) score of > or = 17 points and a nerve-sparing procedure. After 2 years, 48.1, 0 and 0% had an IIEF-5 score of > or = 17 points without the use of phosphodiesterase type 5 (PDE-5) inhibitors, but when including patients using inhibitors there were no significant differences. CONCLUSIONS: A comparison of morbidity, short-term convalescence and long-term side-effects of different surgical techniques is strongly biased by both the preoperative status of patients and the skill of the surgeons. Overall, we found some differences in the short-term results (e.g. early continence) and comparable long-term results.     

Value of extracorporeal piezoelectric lithotripsy in treatment of gallstone disease

Alternative techniques were introduced in the last 20 years for the treatment of gallstones. Among these the extracorporeal shock wave lithotripsy followed by a systemic litholytic therapy represents undoubtedly the most attractive one. A group of two surgeons and two gastroenterologists has started to evaluate this treatment in April 1988, using a piezoceramic lithotryptic system (Piezolith 2300). From April 1988 to May 1989 we have treated 32 patients who fulfilled the selection criteria-symptomatic gallstone disease, 1-3 radiolucent concrements of less than 30 mm of diameter, functioning gallbladder. We noted only one pancreatitis as a complication of this treatment. The overall stonefree rate is 16% after two months, 32% after four months and 56% after six months, depending on the size and number of stones. A definitive evaluation and final conclusion will only be possible when the rate of late recurrences after this treatment will be known.     

Late, Painful, Subungual Hyperkeratosis in Incontinentia Pigmenti

Abstract: The postpubertal appearance of subungual, painful keratotic tumors is a rare feature of incontinentia pigmenti. A patient affected by incontinentia pigmenti developed subungual, painful, nontumoral, hyperkeratotic lesions of the hands at 10 years of age. The mildness of the subungual lesions may be explained by the early stage of the disorder, but it is difficult to correlate the severity of the fingertip pain with the absence of true tumoral swelling. To our knowledge this is the youngest patient reported so far and the only one with a prepubertal expression of this puzzling disorder.     

Management of catheter-related infections in pediatric patients

Broviac catheters are commonly used to provide parenteral nutrition and access for infusion of blood products and drugs to pediatric patients. Sepsis is the most common serious complication of continued catheter use. Although removal of the catheter is generally recommended when it becomes contaminated, it may not be feasible to do so without compromising patient care. We evaluated the management of catheter-related infections in pediatric patients with and without removal of catheter. Seventy-seven episodes of catheter sepsis were evaluated in 61 pediatric patients; 24 were neonates and 37 were older children. The catheters were used for multiple purposes in 75% of cases. The most common microorganisms isolated were Staphylococcus epidermidis in 26%, Klebsiella pneumoniae in 9%, and Streptococcus viridans in 8% of cases; other pathogens included group D Enterococcus, Staphylococcus aureus, and Escherichia coli. Pseudomonas aeruginosa was isolated in four older children. Thirty-five patients were treated with antibiotics without catheter removal. Thirty patients received appropriate antibiotic therapy based on the susceptibility data. Twenty-six of these 30 patients responded within 5 days of therapy whereas the others required 15-39 days of treatment. Lack of response was mainly associated with the presence of abscess, immunocompromised status, and organisms P. aeruginosa and Candida albicans. Based on the sensitivity and minimum inhibitory concentration data, a combined regimen of gentamicin and vancomycin would be an effective initial therapy. These findings suggest that (1) catheter sepsis can be managed with appropriate antibiotics, and (2) when continued use of Broviac catheter is desired, a trial of antibiotic therapy should be attempted before catheter removal.     

Evaluation of Seldinger Technique Emergency Cricothyroidotomy versus Standard Surgical Cricothyroidotomy in 200 Cadavers

Background: Percutaneous cricothyroidotomy is a lifesaving procedure for airway obstruction in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed.

Methods: The purpose of this study was to examine whether there is a training effect using Seldinger technique emergency cricothyroidotomy (group 1; Arndt Emergency Cricothyroidotomy Catheter Set; Cook Critical Care, Bloomington, IN) versus standard surgical cricothyroidotomy (group 2). Twenty emergency physicians performed five cricothyroidotomies with each method in a total of 200 human cadavers, comparing efficacy and safety (speed, success rate, and injuries).

Results: Seven attempts in group 1 and six in group 2 had to be aborted. Time intervals from the start of the procedure to location of the cricothyroid membrane were not significantly different between the groups. However, time to tracheal puncture (P < 0.01) and time to first ventilation (P < 0.001) were significantly longer in group 2. No time effect could be observed in both groups. The airway was accurately placed into the trachea through the cricothyroid membrane in 88.2% (82 of 93) of the cadavers in group 1 and in 84.0% (79 of 94) in group 2 (not significant). No injuries were observed in group 1, whereas there were six punctures of the thyroid vessels in group 2 (P < 0.05).     

In vivo effects of hypothermia on the microcirculation during extracorporeal circulation.

OBJECTIVE: Induced hypothermia has been shown to be protective during cardiac surgery, but also in traumatic, ischemic, burn, and neurological injury. In previous in vivo animal experiments, we documented increased leukocyte/endothelial (L/E) cell interaction following normothermic extracorporeal blood circulation (ECC). This study was carried out to investigate whether reduced core temperature during ECC affects the damage to the microcirculation as evidenced by leukocyte adherence and edema formation. METHODS: Intravital fluorescence microscopy was used on the dorsal skinfold chamber preparation in Syrian golden hamsters. ECC was introduced via a micro-rollerpump (1 ml/min) and a 60 cm silicon tube (1mm inner diameter) shunted between the carotid artery and the jugular vein after application of 300IE Heparin/kg per body weight. Experiments were performed in chronically instrumented, awake animals (age 10-14 weeks, weight 65-75 g). Animals of the experimental group were cooled to 18 degrees C body temperature while ECC, followed by a rewarming period (n=7), controls experienced ECC under normothermia (37 degrees C, n=7). RESULTS: 30 min ECC at 18 degrees C resulted in a decrease of rolling and adherent leucocytes (stickers) in postcapillary venules after 1, 4 and 8h compared with the control group (119+/-46 vs. 274+/-113 n/mm2, P<0.05, mean+/-SD; n=7 in each group). Functional capillary density was significantly reduced during hypothermia (80+/-16 vs. 148+/-16 cm/cm2, P<0.05), but restored after rewarming. In contrast, edema formation was markedly increased during hypothermia. CONCLUSIONS: Hypothermia during ECC significantly reduced L/E cell interaction in the early post-ECC period. Hypothermia markedly reduced microvascular perfusion, but was completely restored upon rewarming. Despite a reduced number of adherent leukocytes, no protection of endothelial barrier function was seen as a consequence of induced hypothermia.