High HIV prevalence among injecting drug users in Estonia: implications for understanding the risk environment

We found a high prevalence of HIV among injecting drug users (IDU) 54% in Tallinn and 90% in Kohtla Jarve, Estonia. Risk factors for HIV in Tallinn included use of the drug 'china white', being registered as an IDU at a drug treatment clinic, and sharing injecting equipment with sex partners. Differences existed in risk behaviour between the cities. An urgent scale-up of HIV prevention is needed. It is also important to explore how local 'risk environments' mediate the risk of HIV transmission.     

Impact of prostate size in robot-assisted radical prostatectomy

BACKGROUND AND PURPOSE: A large prostate can complicate an extraperitoneal robot-assisted radical prostatectomy (RARP). We report our experience with RARP and evaluate the effects of prostate size on treatment outcomes after extraperitoneal RARP. PATIENTS AND METHODS: Information on 355 consecutive patients undergoing extraperitoneal RARP was gathered, and patients with prostate weight <75 g (N = 319) were compared with those having glands >or=75 g (N = 36). The factors considered were age, body mass index, total operating time, estimated blood loss, serum prostate specific antigen (PSA) concentration, pathologic stage and Gleason grade, intraoperative and peri-operative complications, margin status, and continence. RESULTS: A statistically significant difference (P < 0.05) was noted in age (59 v 64 years), PSA concentration (6.07 v 8.9 ng/dL), and blood loss (175 v 226 mL) between patients with smaller v larger prostates. No difference was seen in Gleason score (6 v 6), clinical T stage, operative time (217 v 225 minutes), or total positive-margin rate (13% v 19%). A higher positive-margin rate was seen in patients with stage T(3) disease and larger prostates. The 6-month continence rate in patients with a prostate volume < 75 g was 97% v 84% in patients with larger prostate volumes ( P < 0.05). CONCLUSION: Although a large prostate volume is associated with a slight increase in short-term urinary complications postoperatively, it should not be considered a contraindication for the experienced surgeon. This higher risk raises the question of a possible need for longer catheterization in this subset of patients.     

Impact of shockwave coupling on efficacy of extracorporeal shockwave lithotripsy

PURPOSE: To evaluate the impact of a slow gated treatment rate on the efficacy of extracorporeal shockwave lithotripsy (SWL). PATIENTS AND METHODS: From August 1990 to July 2002, 40,462 SWL procedures were performed using the slow frequency electrocardiography (ECG)-gated lithotripter (82.5%) and fast frequency ECG-ungated (17.5%) modes for the Medstone STS lithotripter. Treatment characteristics, including the mode of SWL, location and size of the stone, re-treatment status, auxiliary procedures required, perioperative complications, and treatment outcomes, were recorded. The stone-free rate was reported by the treating physician on the basis of the finding of no residual stone fragments on a plain radiographic image. RESULTS: The treatment rate for the slow mode was a mean of 79.6 shocks/min, while the rate for the fast mode was 120/min. The total procedure time was 47.0 minutes for the slow mode and 40.6 minutes for the fast. The overall stone-free rate was higher for slow (66.9%) than fast (63.6%) procedures (P < 0.001). The stone-free rate for 1- to 10-mm stones was higher for the slow procedures (75.7%) than the fast procedures (70.7%; P < 0.001). Upper-ureteral stones responded better to slow treatment in terms of stone-free rate (79.5% v 72.6%; P < 0.001), re-treatment rate (6.5% v 8.0%, P = 0.05), auxiliary-procedure rate (6.1% v 8.9%; P = 0.01), and efficiency quotient (71 and 62). There was no significant difference in complication rates overall between slow and fast treatment. CONCLUSIONS: With a minimal increase in procedure time, greater efficacy can be obtained for the treatment of radiopaque stones with a slower shock-delivery rate. In particular, upper-ureteral calculi and calculi <10 mm benefit from a slower treatment rate.     

Is there a proper pelvic size for an extraperitoneal robot-assisted radical prostatectomy?

BACKGROUND: A narrow pelvis can potentially complicate an extraperitoneal radical robot-assisted prostatectomy (RAP). We report our experience with RAP and evaluate whether a narrow pelvis can affect treatment outcomes after extraperitoneal RAP. MATERIALS AND METHODS: We prospectively evaluated 50 patients who underwent RAP during a 2-month period using the extraperitoneal approach. To approximate the relative size of the field available for working using the extraperitoneal approach, the arc length between the anterior superior iliac spines was estimated with the umbilicus as the center of the circle. Patients with an arc length measuring <33 cm were compared with those with an arc length > or =33 cm. Additional parameters evaluated included age, total operating time, estimated blood loss, prostate-specific antigen (PSA) level, pathological stage and Gleason grade, intraoperative and perioperative complications, surgical margin status, and continence at 3 months. RESULTS: Twenty-eight (56%) patients had an arc length <33 cm and twenty-two (44%) patients had an arc length > or =33 cm. When comparing the two groups, no statistically significant difference (P > 0.05) was noted in age, PSA level, blood loss (161 v 163 mL), operative time (174 v 176 min), and total positive margin rates (14% v 13.6%). The continence rate at 3 months was 66.6% and equal for both groups. CONCLUSION: In our experience, a narrow pelvis did not significantly affect operative outcome in patients undergoing an extraperitoneal radical RAP. Although this variable should be taken into account, it should not be a primary factor in deciding the route of access.     

Impact of type of anesthesia on efficacy of medstone STS lithotripter

PURPOSE: To evaluate the impact of the type of anesthesia on treatment efficacy, using a comparison of general anesthesia (GEN) and monitored anesthesia care with intravenous sedation (MAC), for patients undergoing extracorporeal shockwave lithotripsy (SWL) on the Medstone STS lithotripter. PATIENTS AND METHODS: A case-control study was conducted of 660 patients treated from 1986 to 2002. General anesthesia and MAC were utilized in 330 procedures each. Case matching was performed for stone size, stone location, and body mass index. All lithotripter units were staffed by a rotating schedule of the same 10 SWL-certified radiologic technicians. Patient characteristics, treatment parameters, complications, repeat procedures, and secondary procedures were recorded. Stone-free success rates (no residual fragments) were reported by the treating physician on the basis of plain radiographs. Chi-square analysis was used to compare patients in the two groups. RESULTS: The overall stone-free rate was better with GEN (67%) than MAC (55%; P = 0.04). Stone-free rates were not affected for stones 10 mm or in an upper calix. General anesthesia may decrease excursion of the calculus out of the focal area secondary to breathing or patient movement.