Newer techniques in intracorporeal tissue approximation: suturing, tissue adhesives, and microclips

Great strides have been made in the discovery of alternative tissue approximation techniques for use in laparoscopy. Although none of the techniques have eliminated the need for suturing laparoscopically, their potential in achieving this end is promising. When an ideal approximation technique is discovered that is easy to use, safe, and reliably able to hold tissue together laparoscopically, laparoscopic reconstructive surgery should become less formidable and more appealing to urologists.     

Does body mass index have an impact on the rate and location of positive surgical margins following robot assisted radical prostatectomy?

ObjectiveObesity has been shown to be associated with more aggressive prostate cancer. We sought to determine whether body mass index (BMI) has an impact on the rate and location of positive surgical margins (PSM) in robot-assisted laparoscopic radical prostatectomy (RLRP).MethodsRecords of patients undergoing RLRP between the years 2003 and 2009 were retrospectively reviewed. We collected data regarding clinicopathologic data (i.e., age, BMI, PSA levels, Gleason score, pathologic stage, surgical margins status, and location). BMI was categorized as <25, 25–30, and >30 Kg/m². The rates of overall apical, peripheral, and prostate base (PB) PSM were compared across BMI groups.ResultsOverall, 577 records were analyzed. Median age, PSA levels, and BMI were 60.1, 5.3, and 28.2, respectively. Percentage of Gleason score 4, 5, 6, 7, 8, 9 in the entire series was 0.2, 2.1, 40.7, 53, 2.3, and 1.7, respectively. Four hundred eighty-four (81.8%) cases were pathologically organ-confined. The overall incidence of PSM was 23.1% (n = 133) of those 10.2% apical, 3.6% PB and 14.2% peripheral. There were no statistically significant differences found in the rate of PSM by location between BMI groups; however, in the obese group there was a tendency toward slightly higher involvement of the PB with tumor in all stages and greater involvement of all anatomic areas in the T3 pathologic stage.ConclusionsAlthough obesity has been associated with more aggressive prostate cancer, BMI does not appear to have statistically significant influence on the rate and location of PSM in RLRP. Larger studies are required to confirm these findings.     

Hand-assisted laparoscopic approach to simple nephrectomy

Laparoscopic nephrectomy is commonly employed today for both malignant and benign renal conditions, yet the learning curve for all but the simplest procedures remains quite steep. Hand-assisted laparoscopic nephrectomy (HALN) bridges the gap between standard laparoscopy and open surgery, allowing urologists to develop laparoscopic skills while offering the advantages of minimally invasive surgery. Simple laparoscopic nephrectomy, performed for benign disorders, can at times prove to be challenging because of inflammation around the renal hilum. Meticulous dissection during HALN utilizing the intra-abdominal hand for tactile feedback, retraction, and blunt dissection may improve one's capabilities compared with the standard laparoscopic approach.     

Dexamethasone suppression test and selection of antidepressant medications

Endogenous depressives with abnormal dexamethasone suppression tests (DSTs) respond better to somatic antidepressant treatments than those with normal DSTs. Whether the DST also aids in the selection of specific antidepressants has not been determined. A pilot report suggested that patients with abnormal DSTs might be noradrenaline-deficient and respond preferentially to imipramine or desipramine, whereas those with normal DSTs might be serotonin-deficient and respond best to amitriptyline or clomipramine. Attempting to replicate this observation, we studied 26 patients diagnosed with Research Diagnostic Criteria as major depressive disorder, endogenous subtype, and with DSM-III as having melancholia. All were drug-free during baseline evaluation. All had abnormal DST results, with post-dexamethasone plasma cortisol levels exceeding 5 μg/dl. We treated subjects with either imipramine or amitriptyline and compared clinical response with weekly Hamilton Depression Rating Scales, completed by raters blind to both DST results and the research question. Therapeutic plasma levels were documented. We found no significant differences in treatment response between the subgroups. Twenty of the 26 subjects did well. The imipramine-treated group failed to have either earlier response or better final outcome. These data fail to replicate suggestions that DST results assist in the selection of either imipramine or amitriptyline.     

Ventriculoperitoneal shunt migration into the scrotum

Children with hydrocephalus are commonly treated with a ventriculoperitoneal shunt for diversion of cerebrospinal fluid. We report a unique complication: the migration of the ventriculoperitoneal shunt into the scrotum three weeks after placement.     

Structural and electrophysiological changes in the epicardial border zone of canine myocardial infarcts during infarct healing

Structural and electrophysiological properties of the epicardial muscle which survives on the surface of transmural infarcts of the canine heart (epicardial border zone) were studied at different times after occlusion of the left anterior coronary artery (LAD). Isolated preparations were superfused in vitro, transmembrane potentials recorded, and impulse propagation mapped. In preparations from subacute infarcts (1 and 5 days), resting potential, action potential amplitude, upstroke velocity, and duration were all significantly reduced. Well-defined directional differences in propagation occurred. Propagation was more rapid in the direction perpendicular to the left anterior coronary artery than in the direction perpendicular to the base of the heart, because of the uniform anisotropic structure of the surviving muscle fibers which were arranged in tightly packed bundles oriented perpendicular to the left anterior coronary artery. The only ultrastructural abnormalities found in these muscle fibers was an accumulation of large amounts of lipid droplets. As the infarcts healed, resting potential, action potential amplitude, and upstroke velocity returned to normal by 2 weeks, although action potential duration decreased further. Lipid droplets had disappeared, and connective tissue had invaded the epicardial border zone, separating the muscle bundles. By 2 months, action potentials were normal, but the muscle fibers were widely separated and disoriented by the connective tissue (parallel bundles no longer were found). In these regions with a nonuniform anisotropic structure, the well-defined directional differences in impulse propagation were lost. However, activation was very slow, perhaps because of diminished connections between cells. The persistence of slow conduction in healed infarcts may contribute to the occurrence of chronic arrhythmias.