Bladder perforation in a peritoneal dialysis patient

The dysfunction of the catheter in peritoneal dialysis (PD) is a frequent complication. However, perforation of organs are rare, particularly that of the urinary bladder. This requires an early diagnosis and prompt treatment of patients. We report here the case of a 38-year-old woman having end-stage renal disease due to autosomal-dominant polycystic kidney disease treated by PD since November 2000. Three years later, she was treated for Staphylococcal peritonitis. Four months later, she presented with a severe urge to urinate at the time of the fluid exchanges. The biochemical analysis of the fluid from the bladder showed that it was dialysis fluid. Injection of contrast through the catheter demonstrated the presence of a fistula between the bladder and the peritoneal cavity. She underwent cystoscopic closure of the fistulous tract and the PD catheter was removed. Subsequently, the patient was treated by hemodialysis. One month later, a second catheter was implanted surgically after confirming the closure of the fistula. Ten days later, she presented with pain at the catheter site and along the tunnel, which was found to be swollen along its track. The injection of contrast produced swelling of the subcutaneous tunnel but without extravasation of the dye. PD was withdrawn and the patient was put back on hemodialysis. Bladder fistula is a rare complication in PD and diagnosis should be suspected when patient complains of an urge to pass urine during the exchanges, which can be confirmed by contrast study showing presence of dye in the bladder. PD may be possible after the closure of the fistula, but recurrence may occur.     

Short- and long-term outcomes of kidney donors: a report from Tunisia

Kidney transplantation remains the best treatment option of end-stage renal disease. Kidney donations are of particular interest with the currently increasing practice of living-donor transplantation. The purpose of this study was to analyze retrospectively the general health status as well as renal and cardiovascular consequences of living-related kidney donation. A total of 549 living-related kidney donors had donated their kidneys between 1986 and 2007. We attempted to contact all donors to determine short- and long-term outcome following kidney donation. All kidney donors who responded underwent detailed clinical and biochemical evaluation. The data were compared with age-matched health tables of the Tunisian general population. In all, 284 donors (52%) had a complete evaluation. They included 117 men and 167 women with a mean age of 42 ± 12 years. The major peri-operative complications that occurred in these donors included four cases of pneumothorax, six cases of surgical site infection, one case of phlebitis and one case of pulmonary embolism. None of the study cases died. The median length of hospital stay after donor nephrectomy was 6.5 days (range: 3-28 days). The median follow-up period was eight years. The mean creatinine clearance after donation was 90.4 ± 25 mL/min in men and 81.5 ± 27.2 mL/min in women. Proteinuria was >300 mg/24 h in 17 cases (5.9%). Fifty-eight (20.4%) donors became hypertensive and 19.6% of the men and 37.2% of the women became obese. Diabetes mellitus developed in 24 (8.4%), and was more common in patients who had significant weight gain. Our study suggests that kidney donors have minimal adverse effects on overall health status. Regular follow-up identifies at-risk populations and potentially modifiable factors. Creation of a national registry of living donors and their monitoring are an absolute necessity.     

Assessing the cost effectiveness of robotics in urological surgery – a systematic review

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post‐operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery. This review concludes that robotic surgery should be targeted for cost efficiency in order to fully reap the benefits of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review finds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs difficult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it difficult to accurately assess long term post‐operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology.

OBJECTIVES

• ? Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery.
• ? These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes.

METHODS

• ? A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study.

RESULTS

• ? Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1–1.76 days and 1–5.5 days, respectively) and blood loss (range 482–780 mL and 227–234 mL, respectively) when compared with the open approach (range 2–8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000–$39 215) than both laparoscopic (range US $740–$29 771) and open radical prostatectomy (range US $1870–$31 518).
• ? This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1–1.5 days) and length of surgery (range 102–360 min) are unable to compensate for the excess costs.
• ? Robotic surgery may require a smaller learning curve (20–40 cases) although the evidence is inconclusive.

CONCLUSIONS

• ? Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve.
• ? Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs.
• ? Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery.

     

Embryonic exposure to dimethoate and/or deltamethrin impairs sexual development and programs reproductive success in adult male offspring mice

Pesticides can be toxic to desirable plants and animals, including humans. The aim of this study was to investigate the reproductive effects of low doses of pesticides on male offspring of exposed pregnant mice. Three groups of five female mice were treated daily by oral gavage with dimethoate (5 mg kg(-1) per day), deltamethrin (5 mg kg(-1) per day) and their mixture at 5 mg kg(-1) per day from day 3 to day 21 of pregnancy. Fertility, sexual behaviour and a number of reproductive endpoints, such as organ weights, sperm evaluations and testicular histology, were examined on four adult male offspring of exposed pregnant mice. When compared with control, a dose of deltamethrin 5 mg kg j(-1) causes a decrease in the absolute and relative weight of the testes of exposed mice and it affects their fertility by reducing the density, mobility and vitality of sperm and increasing the number of abnormal forms of these cells (P ≤ 0.01). The same results were obtained in mice exposed to a dose of 5 mg kg j(-1) combination of dimethoate and deltamethrin. This study demonstrated that deltamethrin and combination of dimethoate and deltamethrin caused a decrease in the absolute and relative weight of the testes, which affected the sperm parameters of male offspring of exposed mice to a low dose of these pesticides during pregnancy.     

Antioxidant supplementations in vitro improve rat sperm parameters and enhance antioxidant enzyme activities against dimethoate-induced sperm damages

Organophosphorus compounds are currently among the most frequently used pesticides worldwide, and therefore, the potential for human exposure to man is considerable. Their toxicity results in negative effects on many organs and systems such as the male reproductive system. So, vitamins that can offer spermatozoa protection are of great importance. This study was designed to investigate (i) the possibility of dimethoate, an organophosphate insecticide, to induce oxidative stress response in rat spermatozoa in vitro and its effect on antioxidant defence system and (ii) the role of vitamin C and vitamin E in alleviating the cytotoxic effects of dimethoate Epididymal spermatozoa were incubated for 3 h at 37 °C with different concentrations of dimethoate (50, 100 and 200 μm) without vitamins or pre-incubated with 20 mm of vitamin C or 2 mm of vitamin E. Sperm parameters, malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) levels were performed. Dimethoate caused a significant induction of oxidative damage in spermatozoa at different concentrations as evidenced by increased MDA levels. However, a significant decrease in sperm mobility, viability and activities SOD, CAT and GPx was observed. Vitamins pre-treated spermatozoa showed a significant protection against the cytotoxic effects induced by dimethoate on studied parameters.