Robot-assisted radical cystectomy and urinary diversion in female patients: technique with preservation of the uterus and vagina

BACKGROUND: After performing more than 500 robotic radical prostatectomy and robotic radical cystoprostatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy in women. This article describes two techniques of robot-assisted radical cystectomy for women, conventional and with preservation of the uterus and vagina. To the best of our knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion in women. STUDY DESIGN: Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell carcinoma of the urinary bladder. The operation was performed with the conventional anterior approach in one patient and with a new technique in two patients, which allows preservation of urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done robotically, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was performed extracorporeally after exteriorizing the bowel through the incision used for retrieving the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a technique described previously for men. RESULTS: The average operating time for the robotic radical cystectomy was 160 minutes and the mean operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 minutes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients. CONCLUSIONS: This approach incorporates advantages of minimally invasive and open surgery. Performing the radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage of evolution of laparoscopic and robotic instrumentation. In the future, with the development of technology, instrumentation, and with additional refinement of our technique, the entire procedure may be done completely intracorporeally with equal efficiency.     

Mother-to-child transmission of hepatitis E virus infection

Objectives : Water borne or enterically transmitted non-A-non-B hepatitis is a major public health problem in India. Many of these cases carry fatal outcome. The hepatitis E virus (HEV) has been considered to be the most important causative agent of this entity. The severity and fatality rates of HEV infection are reported to be rather more in pregnant women. However, there is meager information from India, on mother to child transmission of this agent.Methods : During 1997-98, we studied 60 pregnant women suspected to have acute viral hepatitis to understand the frequency of various viral etiologies, disease course and outcome of the pregnancy. Six cord blood samples were tested for IgG, and IgM antibodies against hepatropic viral agents and also for hepatitis E virus RNA by RT-nested PCR using ORF-1 as target.Results : Of the 60 pregnant patients hospitalised at All India Institute of Medical Sciences, New Delhi for acute hepatitis, 22 (37%) were positive for IgM anti-HEV antibodies and 10% were infected with hepatitis B virus. Co-infection of HEV with Hepatitis B and C was seen in 1 and 2 patients, respectively. Most (72%) of the HEV infected patients were in third trimester of pregnancy (P<0.05). Of the 6 cord blood samples tested 3 (50%) were positive for HEV RNA. Though, all mothers were RNA positive, half of the babies did not get infectedin utero with HEV. Fourteen of the 22 (63.6%) HEV infected mothers developed fulminant hepatic failure and all died.Conclusion : The mortality rate in HIV infected mothers was 100%. Mother to child transmission of hepatitis E virus infection was established in 50%     

Synthesis,characterization, and blood compatibility of polyamidoamines copolymers

This work reports the development of new non-thrombogenic polymers based on the linear polymers of polyamidoamines (PAAs), having heparin binding ability, obtained by polyaddition of secondary amines to N,N'-methylene bis-acrylamide. PAAs could not be used directly in the making of blood-contacting materials due to their poor mechanical strength. In order to overcome this lacuna, copolymers of amidoamine with methylmethacrylate (MMA) were prepared. Characterization studies indicated that the PAAs have been suitably incorporated into the MMA matrix. The relative hydrophilic nature of the synthesized copolymers was established from the measurement of water contact angle. The heparinized copolymers showed significant improvement in non-thrombogenic characteristics.     

Role of protein kinase C in control of ethanol-modulated beta-endorphin release from hypothalamic neurons in primary cultures

We have previously shown that short-term exposure to ethanol stimulates immunoreactive beta-endorphin (IR-beta-EP) release from hypothalamic neurons and that chronic ethanol exposure decreases the IR-beta-EP release from these neurons. The role of protein kinase C (PKC) in the ethanol-regulated beta-EP release from hypothalamic neurons has not been established. In this study, by using the primary cultures of hypothalamic neurons, we tested the effects of PKC stimulator phorbol ester 4 beta-phorbol 12-myristate-13-acetate (PMA) and PKC inhibitor chelerythrine chloride on ethanol-induced IR-beta-EP release. Additionally, the effects of ethanol with or without PMA on expression and translocation of various PKC isoenzymes from cytosolic to membrane fraction were determined. PMA treatment increased IR-beta-EP release in a time- and dose-dependent manner. Acute ethanol treatment (3 h) increased, while chronic ethanol treatment (24 h) reduced, the magnitude of PMA-induced IR-beta-EP release. The stimulatory effect of acute ethanol on IR-beta-EP release was reduced by chelerythrine chloride. Determination of the effects of ethanol with or without PMA on seven different PKC isoenzymes (PKC-alpha, -beta I, -beta II, -gamma, -delta, -epsilon, and -zeta) revealed that the expression and translocation of only two PKC isoenzymes, PKC-delta and PKC-epsilon, were stimulated by acute treatment with ethanol. Acute ethanol also increased PMA-stimulated expression of these two isoenzymes. Chronic ethanol treatment reduced both basal and PMA-induced increase of PKC-delta and PKC-epsilon expression and translocation. These data provide evidence for the first time that ethanol-regulated IR-beta-EP secretion is controlled by the PKC system, possibly involving PKC-delta and PKC-epsilon isoenzymes.     

Vattikuti Institute Prostatectomy: a single-team experience of 100 cases

PURPOSE: To analyze the outcomes of the first 100 patients undergoing robotic radical prostatectomy by a single surgical team. PATIENTS AND METHODS: From August 2001 to May 2002, we performed robotic radical prostatectomy in 100 patients with localized prostate cancer. The mean age was 60 +/- 0.67 years (SEM), the body mass index 27.5 +/- 0.35, the preoperative prostate specific antigen concentration 7.2 +/- 0.86 ng/mL, and follow-up 5.5 +/- 0.24 months. Thirty-eight patients also underwent pelvic lymph node dissection. We used the da Vinci surgical system and a subperitoneal approach (the Vattikuti Institute Prostatectomy; VIP). This is a prospective outcomes analysis of these patients. RESULTS: The mean operating time was 195 +/- 5.0 minutes, and the mean blood loss was 149 +/- 11.8 mL. No patient required blood transfusion. The stages of the cancers were pT(2a) in 21, pT(2b) in 64, pT(3a) in 5, pT(3b) in 9, and pT(3b)N(1) in 1. The positive surgical margin rate was 15%. At 1, 3, and 6 months, the continence rates were 37%, 72%, and 92%, respectively, and the potency rates were 11%, 32%, and 59%. CONCLUSION: The VIP is a safe operation with excellent operative parameters, low morbidity, and good surgical margins. The early functional results are promising.     

The influence of peripheral vascular disease on the carotid and femoral wall mechanics in subjects with abdominal aortic aneurysm

AIM: Aortic and carotid stiffness is elevated in patients with abdominal aortic aneurysm (AAA). Peripheral vascular disease (PVD) frequently coexists with AAA and may further impair the arterial wall mechanics and increase the cardiovascular load. We therefore studied the elastic carotid and muscular femoral biomechanical properties and intima-media thickness (IMT) in this group of patients. METHODS: The elastic indices and IMTs of the common carotid and common femoral arteries were determined in 30 patients with AAA (15 with PVD) with a duplex scanner coupled with a wall tracking system. Fasting plasma creatinine level, glucose and lipid concentrations, and their physiologic variables known to influence the arterial wall mechanics were also assessed. RESULTS: Patients with AAA and PVD have significantly stiffer carotid (Petersen's elastic modulus, 2207 +/- 905 mm Hg versus 1268 +/- 432 mm Hg; P =.001; stiffness index, 22.73 +/- 9.63 versus 12.60 +/- 4.24; P =.001] and femoral (Petersen's elastic modulus, 4906 +/- 4057 mm Hg versus 2599 +/- 1169 mm Hg; P =.043; stiffness index, 49.02 +/- 40.04 versus 26.07 +/- 13.22; P =.044) arteries than subjects with AAA alone. Although patients with PVD have thicker carotid and femoral IMTs, no statistical difference was seen between the two groups. The subjects were matched for age, body mass index, heart rate, systolic and diastolic blood pressures, total vascular risk score, plasma creatinine level, and fasting lipid and glucose concentrations. CONCLUSION: Subjects with PVD and AAA have significantly stiffer carotid and femoral arteries, which may indicate increased cardiovascular load and may account for the highest mortality rate seen in these patients in the UK Small Aneurysm Trial. Therefore, treatment of associated cardiovascular risk factors is important and may have to be tailored on an individual basis according to the findings of the arterial wall mechanics.