The effect of the modified Z trendelenburg position on intraocular pressure during robotic assisted laparoscopic radical prostatectomy: a randomized, controlled study.

PURPOSE: The Trendelenburg position has a dramatic effect on circulation, consequently increasing cerebral and intraocular pressure. We evaluated whether modifying the Trendelenburg position would minimize the increase in intraocular pressure. MATERIALS AND METHODS: In this prospective, randomized, controlled study we compared intraocular pressure in patients undergoing robot-assisted laparoscopic radical prostatectomy while in the Trendelenburg position or the modified Z Trendelenburg position. In group 1 intraocular pressure, blood pressure and endotracheal CO2 were measured in the patient at anesthesia induction (time 1), before positioning (time 2), and while in the Trendelenburg position (time 3) and in the modified Z Trendelenburg position (time 4). They were also measured after pneumoperitoneum (time 5), every 30 minutes (times 6 to 16), while supine at the end of pneumoperitoneum (time 17) and before awakening (time 18). We modified the Trendelenburg position by placing the head and shoulders horizontally. RESULTS: Group 1 included 29 patients in the modified Z Trendelenburg position. Group 2 included 21 patients in the Trendelenburg position. No difference was found in patient demographics or surgical outcomes. Median intraocular pressure was in the low normal range at times 1 and 2, and increased in time 3 in each group. From time 4 intraocular pressure decreased and at all time points it was significantly lower in group 1 by a mean of 4.61 mm Hg (95% CI -6.90-2.30, p <0.001). At time 17 mean intraocular pressure decreased to normal (19.6 mm Hg) in group 1 but remained in the hypertensive range (24.9 mm Hg) in group 2. At time 18 mean intraocular pressure was 17 mm Hg in each group. Blood pressure was significantly lower in group 1 with a mean reduction in systolic and diastolic pressure of 6.3 and 4.3 mm Hg, respectively. CONCLUSIONS: Our results suggest that modifying the Trendelenburg position during robot-assisted laparoscopic radical prostatectomy has a significant positive effect on patient neuro-ocular safety by lowering intraocular pressure and accelerating its recovery to the normal range without affecting the operation.

Osteoporosis from androgen deprivation therapy in prostate cancer treatment.

BACKGROUND: Bone complications from metastatic disease in prostate cancer have been well documented. Osteoporosis from androgen deprivation therapy (ADT) can further impair quality of life in this already susceptible age group. OBJECTIVE: We aimed to assess the intermediate and long term effects of ADT on bone density and the development of osteoporosis in men with prostatic cancer, and outline some practical assessment, management and treatment options. DISCUSSION: Osteoporosis, exacerbated by the use of ADT, reduces both the survival and quality of life of men who may otherwise live for many years with their well controlled prostate cancer. Hence, both preventive and treatment options should be explored and tailored to the individual, including lifestyle modifications (exercise, smoking cessation), vitamin D and calcium supplementation, and the use of bisphosphonates.

Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers.

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Retrieval of a detached resectoscope sheath beak during a TURP.

The detachment of a resectoscope beak during transurethral resection is a rare and unpleasant event. Published techniques for its retrieval are not practical to the majority of urologists. The authors outline a novel approach for the retrieval of a detached continuous-flow resectoscope plastic beak that is quick, safe, and effective. The plastic beak is extracted at the time of detachment using standard continuous-flow resectoscope equipment. This has increased patient safety as no further loss of time and blood resulted from the delay associated with the more conventional approaches.