Does Functional Mitral Regurgitation Improve with Isolated Aortic Valve Replacement?

BACKGROUND: The surgical treatment of mitral valve regurgitation (MR) at the time of aortic valve replacement (AVR) remains controversial. The purpose of this study was to evaluate the change in severity of MR following isolated AVR, and to determine survival benefit. METHODS: Between 1991 and 2001, 250 patients underwent isolated AVR; 196 patients had concomitant functional MR. Follow-up transthoracic echocardiography (TTE) was available on 107 patients, with a median of 818 +/- 752 days. Aortic valve was stenotic in 77 and regurgitant in 30 patients. RESULTS: Mean age was 67 +/- 15 years and 57 (53%) were male. Preoperative MR was trivial (1+) in 27 (25%), mild (2+) in 44 (41%), moderate (3+) in 29 (27%), and severe (4+) in 7 (7%). At follow-up TTE, MR improved by 1 or 2 grades in 48 patients (45%). Of patients with preoperative 2+ MR, 19 (43%) improved, 16 (36%) remained unchanged, and 9 (21%) worsened. Although some patients with preoperative 3+ MR exhibited improvement, 11 (38%) remained with moderate-to-severe MR. Of those with a preoperative MR of 4+, 3 (71%) improved, and 4 remained with 3-4+ MR. For patients with preoperative 1 to 2+ MR, survival at 3 years was 98% compared to 78% for those with 3 to 4+ MR (p = 0.038). CONCLUSION: Functional MR does not always improve after isolated AVR. Survival is lower for patients with preoperative 3 to 4+ MR. Moderate-to-severe MR should be repaired at the time of aortic valve surgery.     

How to decrease pain during transrectal ultrasound guided prostate biopsy: a look at the literature

PURPOSE: There is growing interest among urologists on the need for decreasing pain during transrectal ultrasound (TRUS) guided prostate biopsy. MATERIALS AND METHODS: We performed a systematic MEDLINE search of clinical trials of any kind of anesthesia, analgesia or sedation during TRUS guided prostate biopsy published since 2000. We critically analyzed the impact of pain and discomfort associated with the procedure, the described methods for evaluating it and the different techniques that have been described. RESULTS: There is strong evidence in the current literature that patient tolerance and comfort during TRUS guided prostate biopsy can be improved by anesthesia/analgesia. What remains is the need to urge all urologists to introduce it in clinical practice as a routine part of the procedure, whatever the biopsy scheme. CONCLUSIONS: Of the various options periprostatic anesthetic infiltration has been shown to be safe, easy to perform and highly effective. It should be considered the gold standard at the moment, even if the optimal technique remains to be established. Further studies addressing this issue are warranted.     

Are extended biopsies really necessary to improve prostate cancer detection?

The aim of this study is to understand the value of specific sites in extended peripheral and transition zone biopsy schemes in order to define the optimal systematic biopsy regimen correlated with the percentage of positivity of each single bioptic site. A total of 165 consecutive patients underwent transrectal ultrasonography examination to detect prostate cancer followed by a lesion-directed and systematic 14-step biopsy scheme. The detection rate was examined for the lesion-directed and for each zone region biopsy. The frequency of positive biopsies in the various prostate regions was determined to evaluate the diagnostic yield of each biopsy site. Analysis was stratified for prostate-specific antigen (PSA), free-to-total PSA ratio, age, prostate size and digital rectal examination. The biopsy protocol detected 40% of patients (66/165) as positive and 55.1% (91/165) as negative for cancer. Standard sextant biopsy was expected to detect only 51 cancer on 66, lateral peripheral (PZ), transition (TZ) and central zone (CZ) biopsies only 56 cancer on 66, while the combination of sextant, PZ, TZ and CZ biopsies, for a total of 14 zone biopsies, detected 64 on 66 patients with cancer (97%) at recruitment. Sampling only the eight prostate regions with higher frequency of positive cancer biopsy was expected to detect 61 cancer patients against the 64 found with the 14-step scheme. This eight-biopsy regimen outperforms the conventional sextant regimen in cancer detection rate (93 vs 77%) and has an overall detection rate lower by only 3.1% (36.9 vs 40%) compared to the 14-biopsy regimen. This difference in detection rate is even smaller in patients with PSA values <10 ng/ml, age <70 y and prostate size <50 ml. This eight-biopsy scheme, including sampling in PZ and TZ toward the base, should be considered in an initial biopsy scheme to maintain a similar detection rate of an extensive biopsy scheme reducing the number of biopsies.     

Impact of laparoscopy on the management of an unusual case of nonpalpable testis in an adult patient

Background: In the past decade, cryptorchidism has generally been treated in the first 36 months of life using an inguinal approach, in the case of palpable testis, or using laparoscopy, in the case of nonpalpable testis. Nevertheless, before this period some children were managed incorrectly. This case report shows how laparoscopy and the collaboration between pediatric surgeons and urologists may lead to optimal results. Case report: A 19-year-old male was referred to our unit following routine medical examination for enrollment in the military service with a diagnosis of right cryptorchidism. The clinical history showed the anamnesis of right cryptorchidism diagnosed at birth as a right nonpalpable testis, confirmed at 2 years of age with clinical examination and computer tomography. The patient came to our attention to again undergo a clinical examination, ultrasonography, computed tomography, and magnetic resonance imaging. We found a left, well-positioned testis of 20 ml in volume and an empty right scrotum; all the instrumental examinations were negative. The patient was thus scheduled for a diagnostic laparoscopy. A pediatric surgeon with extensive experience in this pathology performed the procedure. The 10-mm 30° optics introduced through the umbilicus showed a closed right inguinal ring, with no evidence of either vas deferens or inner spermatic vessels at the level of the inguinal region or pelvis. Two more trocars were introduced and a testis of 15 ml in volume was found under the ascending colon 10 cm away from the cecum. An orchiectomy was performed via laparoscopy. Conclusion: This case clearly shows that some males with nonpalpable testis may have been treated incorrectly in the prelaparoscopic era and may now have an intraabdominal testis. In addition, our experience shows that intraabdominal testis may sometime be in an unusual location, and a laparoscopic surgeon with experience in this pathology is fundamental to finding the testis. In the case of adults with nonpalpable testis, when echography, computed tomography, and magnetic resonance imaging are not useful, the only effective diagnostic procedure is laparoscopy.     

Cavo-portal transposition in rat: a new simple model

Background  

Liver transplantation in presence of diffuse portal vein thrombosis is possible by using caval blood as portal inflow, through cavo-portal transposition. However, clinical results are heterogeneous and experimental studies are needed, but similar hemodynamic conditions are difficult to obtain, especially in small animals. Herein we describe a new simple model of cavo-portal transposition in rat.     

The effect of robotic assistance on learning curves for basic laparoscopic skills

BACKGROUND: We hypothesized that laparoscopic tasks performed with ZEUS robotic assistance would be done with greater precision and with a different learning curve than when performed in a standard laparoscopic trainer. METHODS: Participants were divided into the surgically experienced (n = 11) and the surgically naive (n = 17). Two laparoscopic tasks (bead transfer and rope pass) were repeated for five repetitions. RESULTS: For all drills and participants, completion time and error rate decreased across the five repetitions for each platform. Precision averaged 97% for both platforms over all drills. For both groups, completion time for tasks was shorter on the laparoscopic platform. ZEUS allowed for greater consistency in performance. CONCLUSIONS: Compared with performance on a standard laparoscopic trainer, robotic assistance allows for increasing speed and consistency while maintaining precision over multiple repetitions. Understanding how robotics affects learning curves will allow for modifications in the training experience with this new technology.     

Influence of internal mammary artery grafting and completeness of revascularization on long-term outcome in octogenarians

Background. It has been well established that complete revascularization with internal mammary artery (IMA) grafting is important in young patients undergoing coronary artery bypass grafting (CABG). Applying these principles to octogenarians remains controversial.Methods. From 1986 to 1999, 358 consecutive patients aged 80 to 94 years underwent CABG. Revascularization was complete in 291 (81%) and incomplete in 67 (19%). The IMA was used in 231 (65%) cases.Results. Operative mortality was 7% ± 1%, but was not statistically different with or without IMA grafting (IMA 5% ± 2% versus no IMA 10% ± 3%, p = 0.11) or complete revascularization (p > 0.41). Midterm survival improved with IMA grafting (70% ± 3% versus 56% ± 5% at 4 years, p < 0.03; 36% ± 4% versus 29% ± 5% at 8 years, p < 0.08), but was not significant beyond 8 years. Among 138 survivors, those with IMA grafts were more likely to be angina free (82% versus 53%, p < 0.001) and in New York Heart Association class I (60% versus 36%, p < 0.03). Survival, recurrent angina, and functional class were independent of completeness of revascularization (p > 0.21).Conclusions. IMA grafting improved survival, angina, and functional class of octogenarians, but complete revascularization did not have a similar impact.