Robotic versus laparoscopic adrenalectomy: a comparative study in a high-volume center

Background

Minimally invasive surgery has become more popular in recent years. The da Vinci^® robot is one of the new technologies the use of which has gained popularity in a host of different specialties. Originally used in cardiac surgery, marked increases in utilization have been seen in urology, gynecology, and thoracic surgery. Use in general surgical procedures has now become more common. The objective benefits of the robot are unclear compared to those of laparoscopy in many procedures. The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for adrenalectomy in a high-volume center compared to routine laparoscopic techniques.

Methods

We conducted a retrospective study including consecutive patients who underwent minimally invasive adrenalectomy in a tertiary referral center at the University of Alabama Birmingham. Demographic, clinical, histopathological, and surgical variables were recorded. Patients were divided in two groups: laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA). Groups were compared using the χ² test for categorical variables and Student’s t-test for continuous variables. Significance was considered p < 0.05.

Results

Sixty patients were included, with 30 patients in each group. There were no significant differences between groups with respect to demographic variables except there were more pheochromocytoma patients in the LA group than in the RA group (13/30 vs. 5/30, respectively; p = 0.02). This study demonstrated increased operative time in the robotic group (190 ± 33 min) versus the laparoscopic group (160 ± 41 min) (p = 0.003). There was a trend for less blood loss in RA versus LA (30 ± 5 ml vs. 55 ± 74 ml; p = 0.07). There was no mortality. Morbidity and length of hospital stay were similar for both groups.

Conclusions

Robotic adrenalectomy is as safe and technically feasible as laparoscopic adrenalectomy. Subjective benefits for the surgeon with robot-assisted surgery include three-dimensional operative view, ergonomically comfortable position, and elimination of the surgeon’s tremor. The operating time is significantly longer but patient outcomes are similar to those of the laparoscopic technique.     

Hereditary gastric cancer. Genetics and clinical management

Recently, germline mutations in the E-cadherin/CDH1 gene have been identified in families with an autosomal-dominant inherited predisposition to gastric cancer of the diffuse type. Criteria to define familial gastric cancer syndromes have been proposed and include review of the histopathology and pedigree analysis of any family with an aggregation of gastric cancer cases. Of families with two or more cases of diffuse gastric cancer in first- or second-degree relatives < 50 years of age or three or more cases at any age, up to half may be attributable to inherited germline mutations in the E-cadherin/CDH1 gene. Cumulative lifetime risk of developing gastric cancer in CDH1 mutation carriers is 70%, women from these families also have increased risk for developing lobular breast cancer. Prophylactic gastrectomies have been performed in several unaffected CDH1 mutation carriers; despite normal endoscopic examinations and negative gastric biopsy specimens, pathologic foci of early gastric cancer were found in all surgical specimens. Based on these results, guidelines for genetic testing, counseling and management of individuals with hereditary diffuse gastric cancer have been proposed. Raised awareness among the physician community regarding this syndrome may allow for increased detection and prevention of gastric and breast cancers in these high-risk individuals.     

Isolation of 10 differentially expressed cDNAs in p53-induced apoptosis: activation of the vertebrate homologue of the drosophila seven in absentia gene.

We report the isolation of 10 differentially expressed cDNAs in the process of apoptosis induced by the p53 tamor suppressor. As a global analytical method, we performed a differential display of mRNA between mouse M1 myeloid leukemia cells and derived clone LTR6 cells, which contain a stably transfected temperature-sensitive mutant of p53. At 32 degrees C wild-type p53 function is activated in LTR6 cells, resulting in programmed cell death. Eight genes are activated (TSAP; tumor suppressor activated pathway), and two are inhibited (TSIP, tumor suppressor inhibited pathway) in their expression. None of the 10 sequences has hitherto been recognized as part of the p53 signaling pathway. Three TSAPs are homologous to known genes. TSAP1 corresponds to phospholipase C beta 4. TSAP2 has a conserved domain homologous to a multiple endocrine neoplasia I (ZFM1) candidate gene. TSAP3 is the mouse homologue of the Drosophila seven in absentia gene. These data provide novel molecules involved in the pathway of wild-type p53 activation. They establish a functional link between a homologue of a conserved developmental Drosophila gene and signal transduction in tumor suppression leading to programmed cell death.     

Activation of the human homologue of the Drosophila sina gene in apoptosis and tumor suppression.

Developmentally regulated genes in Drosophila, which are conserved through evolution, are potential candidates for key functions in biological processes such as cell cycle, programmed cell death, and cancer. We report cloning and characterization of the human homologue of the Drosophila seven in absentia gene (HUMSIAH), which codes for a 282 amino acids putative zinc finger protein. HUMSIAH is localized on human chromosome 16q12-q13. This gene is activated during the physiological program of cell death in the intestinal epithelium. Moreover, human cancer-derived cells selected for suppression of their tumorigenic phenotype exhibit constitutively elevated levels of HUMSIAH mRNA. A similar pattern of expression is also displayed by the p21waf1. These results suggest that mammalian seven in absentia gene, which is a target for activation by p53, may play a role in apoptosis and tumor suppression.     

Low maternal nutrition during pregnancy reduces the number of Sertoli cells in the newborn lamb

The nutritional status of females during pregnancy can play a critical role in the postnatal growth and development of the offspring, often leading to permanent changes ('fetal programming'). The Sertoli cells are a strong candidate for fetal programming of future performance because the number of Sertoli cells is highly correlated with adult testicular size and the maximum rate of sperm production. For Merino ewes, we imposed different levels of metabolizable energy (ME) intake (LowME: 70% of requirements for maintenance of ewe body mass and normal growth of conceptus (n = 13); HighME: 110% of those requirements (n = 12)) from Week 10 of pregnancy until parturition and then tested for effects on testicular histology in newborn males. Pregnant ewes were weighed weekly and lambs were weighed at birth and 2 days later. Blood was sampled at the same times. LowME ewes did not gain weight, whereas HighME ewes gained 17% over their pretreatment weight. Birthweights were higher in HighME lambs than in LowME lambs. Paired testes tended to be heavier in the HighME group than in the LowME group (P=0.08). The diameter of the testicular cords did not differ. The absolute volume of testicular cords (0.36 +/- 0.02 v. 0.30 +/- 0.02 mL for HighME v. LowME, respectively; P=0.03) and the number of Sertoli cells (43.0 +/- 2.5 v. 34.5 +/- 2.0 x 10(8) for HighME v. LowME, respectively; P=0.018) per testis were both greater in the HighME than in the LowME group. Plasma follicle-stimulating hormone concentrations were not significantly affected at birth or 2 days later. We conclude that undernutrition during pregnancy can reduce testicular development in the newborn. Depending on the ability of the Sertoli cell population to recover between birth and puberty, this may limit the ultimate number of Sertoli cells and, hence, the future capacity for sperm production and fertility.