Effect of patient-ventilator asynchrony on lung and diaphragmatic injury in experimental acute respiratory distress syndrome in a porcine model.

BACKGROUND: Patient-ventilator asynchrony during mechanical ventilation may exacerbate lung and diaphragm injury in spontaneously breathing subjects. We investigated whether subject-ventilator asynchrony increases lung or diaphragmatic injury in a porcine model of acute respiratory distress syndrome (ARDS). METHODS: ARDS was induced in adult female pigs by lung lavage and injurious ventilation before mechanical ventilation by pressure assist-control for 12 h. Mechanically ventilated pigs were randomised to breathe spontaneously with or without induced subject-ventilator asynchrony or neuromuscular block (n=7 per group). Subject-ventilator asynchrony was produced by ineffective, auto-, or double-triggering of spontaneous breaths. The primary outcome was mean alveolar septal thickness (where thickening of the alveolar wall indicates worse lung injury). Secondary outcomes included distribution of ventilation (electrical impedance tomography), lung morphometric analysis, inflammatory biomarkers (gene expression), lung wet-to-dry weight ratio, and diaphragmatic muscle fibre thickness. RESULTS: Subject-ventilator asynchrony (median [interquartile range] 28.8% [10.4] asynchronous breaths of total breaths; n=7) did not increase mean alveolar septal thickness compared with synchronous spontaneous breathing (asynchronous breaths 1.0% [1.6] of total breaths; n=7). There was no difference in mean alveolar septal thickness throughout upper and lower lung lobes between pigs randomised to subject-ventilator asynchrony vs synchronous spontaneous breathing (87.3-92.2 µm after subject-ventilator asynchrony, compared with 84.1-95.0 µm in synchronised spontaneous breathing;). There were also no differences between groups in wet-to-dry weight ratio, diaphragmatic muscle fibre thickness, atelectasis, lung aeration, or mRNA expression levels for inflammatory cytokines pivotal in ARDS pathogenesis. CONCLUSIONS: Subject-ventilator asynchrony during spontaneous breathing did not exacerbate lung injury and dysfunction in experimental porcine ARDS.

A Fatal Case of Metastatic Pulmonary Calcification during the Puerperium.

We present an unusual case of a fatal respiratory failure in a young woman developed two weeks after she gave birth at home. Circumstantial and clinical features of the case were strongly suggestive for a 'classical' septic origin of the respiratory symptoms. Autopsy, together with histopathological and immunohistochemical analyses allowed demonstrating a massive calcium redistribution consisting of an important osteolysis, especially from cranial bones and abnormal accumulation in lungs and other organs. Such physiopathology was driven by a primary hyperparathyroidism secondary to a parathyroid carcinoma as demonstrated by immunohistochemistry. This very rare case is furthermore characterised by a regular pregnancy course, ended with the birth of a healthy new-born. A complex interaction between pregnancy physiology and hyperparathyroidism might be hypothesised, determining the discrepancy between the relative long period of wellness and the tumultuous cascade occurred in the puerperium.

Insights into Punic genetic signatures in the southern necropolis of Tharros (Sardinia).

BACKGROUND: Phoenician and Punic expansions have been protagonists of intense trade networks and settlements in the Mediterranean Sea. AIMS: The maternal genetic variability of ancient Punic samples from the Sardinian necropolis of Tharros was analysed, with the aim to explore genetic interactions and signatures of past population events. SUBJECTS AND METHODS: The mtDNA HVS-I and coding region SNPs were analysed in 14 Punic samples and 74 modern individuals from Cabras and Belvì (for which the HVS-II region was also analysed). The results were compared with 5,590 modern Euro-Mediterranean sequences and 127 ancient samples. RESULTS: While contemporary groups fall within the genetic variability of other modern Sardinians, our Punic samples reveal proximity to present-day North-African and Iberian populations. Furthermore, Cabras and Belvì cluster mainly with pre-Phoenician groups, while samples from Tharros project with other Punic Sardinian individuals. CONCLUSION: This study provides the first preliminary insights into the population dynamics of the Punic site of Tharros. While the number of currently available samples does not allow definitive investigation of the connection with indigenous Sardinian groups, our results seem to confirm internal migratory phenomena in the central-western Mediterranean and female participation in the Punic mobility.

Population health model for pharmacist assessment and independent prescribing of statins in an ambulatory care setting.

OBJECTIVE: This study aimed to evaluate the impact of a pharmacist population health initiative on the ability to increase the percentage of patients with atherosclerotic cardiovascular disease (ASCVD) who are on an appropriate statin. SETTING: Ten primary care clinics in Southwest Washington. The average payer mix across the included clinics is 47% Medicare, 26% commercial, 22% Medicaid, 2% self-pay, and 3% other. Reimbursement-tied statin quality metrics are present in 14.1% of patients' insurance contracts. PRACTICE DESCRIPTION: The primary care pharmacy collaborative drug therapy agreement allows pharmacists to act as prescribers by permitting initiation, adjustment, and monitoring of medication therapy, with the authority historically stemming from referral by the patient's primary care provider to the pharmacist. PRACTICE INNOVATION: A novel, population health protocolized prescriptive authority (PPA) initiative was implemented, of which a key component was expanding pharmacists' prescriptive authority to prescribe statins for population health initiatives. Without referral, pharmacists screened, directly outreached to, and prescribed statins for patients with ASCVD who were not on a moderate- or high-intensity statin. Electronic health record (EHR) documentation was updated to better reflect the patient's history and increase metric accuracy. EVALUATION: A retrospective analysis of a population health initiative from October 1 to December 31, 2018. The initiative was evaluated on the combined success of initiating patients with ASCVD on moderate- or high-intensity statins and the acceptance rate of EHR corrections. RESULTS: The pharmacy team screened 510 patients. Appropriately dosed statins were initiated for 40.0% of patients, and the EHR was accurately updated in 91.9% of instances. These combined efforts demonstrate 50.5% overall success of pharmacist interventions. CONCLUSION: Expanding pharmacists' authority to PPA for statin medications in patients not meeting quality metrics increased the number of successful interventions. Pharmacists make a major contribution on improving population health metrics for statins.

Residency pathways to ambulatory care practice: Essential insights for students, residents, and educators.

OBJECTIVE: To provide a guiding document describing residency training opportunities in ambulatory care for students, postgraduate year 1 (PGY1) residents, practicing pharmacists, and pharmacy educators. SUMMARY: Student pharmacists, residents, practitioners, and educators can benefit from a guiding document describing the various pathways to develop as an ambulatory care practitioner through residency training. The benefits and differences of PGY1 and postgraduate year 2 (PGY2) ambulatory care residency programs are included. CONCLUSION: There are many possible training options for pharmacists interested in pursuing a career in ambulatory care pharmacy practice. In addition to the required ambulatory and community experience required for all Doctorate of Pharmacy students, postgraduate training in an ambulatory environment can allow for specialization. Candidates for residency training can complete a PGY1 pharmacy residency or a PGY1 community-based pharmacy residency, possibly followed by a PGY2 ambulatory care residency. Career paths for ambulatory care pharmacists vary regionally across the country according to competition for positions, local availability of training programs, and the experience of regional leaders. A comprehensive description of these available training pathways and advantages of each are beneficial for students, residents, practicing pharmacists, and educators.

Pharmacogenomics of clinical response to Natalizumab in multiple sclerosis: a genome-wide multi-centric association study.

BACKGROUND: Inter-individual differences in treatment response are marked in multiple sclerosis (MS). This is true for Natalizumab (NTZ), to which a subset of patients displays sub-optimal treatment response. We conducted a multi-centric genome-wide association study (GWAS), with additional pathway and network analysis to identify genetic predictors of response to NTZ. METHODS: MS patients from three different centers were included. Response to NTZ was dichotomized, nominating responders (R) relapse-free patients and non-responders (NR) all the others, over a follow-up of 4 years. Association analysis on ~ 4.7 M imputed autosomal common single-nucleotide polymorphisms (SNPs) was performed fitting logistic regression models, adjusted for baseline covariates, followed by meta-analysis at SNP and gene level. Finally, these signals were projected onto STRING interactome, to elicit modules and hub genes linked to response. RESULTS: Overall, 1834 patients were included: 119 from Italy (R = 94, NR = 25), 81 from Germany (R = 61, NR = 20), and 1634 from Sweden (R = 1349, NR = 285). The top-associated variant was rs11132400T (p = 1.33 × 10-6, OR = 0.58), affecting expression of several genes in the locus, like KLKB1. The interactome analysis implicated a module of 135 genes, with over-representation of terms like canonical WNT signaling pathway (padjust = 7.08 × 10-6). Response-associated genes like GRB2 and LRP6, already implicated in MS pathogenesis, were topologically prioritized within the module. CONCLUSION: This GWAS, the largest pharmacogenomic study of response to NTZ, suggested MS-implicated genes and Wnt/ß-catenin signaling pathway, an essential component for blood-brain barrier formation and maintenance, to be related to treatment response.

Managing bottlenecks in the perioperative setting: Optimizing patient care and reducing costs.

Bottlenecks limit the maximum output of a system and indicate operational congestion points in process management. Bottlenecks also affect perioperative care and include dimensions such as infrastructure, architectural design and limitations, inefficient equipment and material supply chains, communication-related limitations on the flow of information, and patient- or staff-related factors. Improvement of workflow is, therefore, becoming a priority in most healthcare settings. We provide an overview of bottleneck management in the perioperative setting and introduce dimensions, including aligned strategic decision-making, tactical planning, and operational adjustments.

The Great pretender: the first case of septic shock due to Capnocytophaga canimorsus in Sardinia. A Case report and review of the literature.

Capnocytophaga canimorsus (C. canimorsus) is an emerging pathogen in critical care. C. canimorsus is a Gram-negative bacillus, commonly isolated as a commensal microorganism of the oral flora of healthy dogs and cats. A 63-year-old woman came to the emergency department with fever, chills, and malaise 2 days after a minor dog bite. After admission to the medicine ward, she developed respiratory failure and livedo reticularis. In the intensive care unit (ICU), she presented full-blown septic shock with thrombocytopenia, coagulopathy, severe acute kidney injury, and liver injury. We describe the first case of septic shock with Multiple Organ Dysfunction Syndrome related to Capnocytophaga canimorsus infection in Sardinia and its treatment in a tertiary hospital ICU. We also review recent literature on the relevance of C. canimorsus in human disease and critical illness.

Effect of LTRA in L-ASA Challenge for Aspirin-Exacerbated Respiratory Disease Diagnosis.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) consists of asthma, chronic rhinosinusitis with polyps, and hypersensitivity to aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Nasal Lysine Aspirin Challenge is an effective tool for the diagnosis of hypersensitivity to aspirin and/or NSAIDs in patients with AERD. However, there is no unified international consensus version to perform nasal provocation tests (NPTs). OBJECTIVE: To investigate the effect of a leukotriene receptor antagonist (LTRA), montelukast, on the lysine-acetylsalicylate (L-ASA) nasal challenge. METHODS: We included 86 patients divided into 3 samples: group A (AERD without LTRA), group B (AERD with LTRA), and the control group (NSAID-tolerant asthmatics). NPT with L-ASA was performed with 25 mg of L-ASA every 30 minutes 4 times followed by rhinomanometry and spirometric measurements and evaluation of symptoms using a novel clinical scale. RESULTS: In group A, 94.5% of patients (35 of 37) developed a positive response to NPT (drop >40% in total nasal flow), whereas only 46% of group B subjects (13 of 28) showed a positive response to the nasal challenge (P < .001). Control subjects did not show any response to the L-ASA challenge. A novel clinical score demonstrated accuracy in classifying the hypersensitivity to aspirin and/or NSAIDs when patients avoid LTRA (33 of 37). CONCLUSION: Patients with AERD without LTRA showed a greater positive response to the L-ASA challenge than those taking this drug; therefore, LTRA treatment should be discontinued before the challenge for optimal diagnostic accuracy.

Techno-environmental assessment of the green biorefinery concept: Combining process simulation and life cycle assessment at an early design stage.

The Green biorefinery (GBR) is a biorefinery concept that converts fresh biomass into value-added products. The present study combines a Process Flowsheet Simulation (PFS) and Life Cycle Assessment (LCA) to evaluate the technical and environmental performance of different GBR configurations and the cascading utilization of the GBR output. The GBR configurations considered in this study, test alternatives in the three main steps of green-biorefining: fractionation, precipitation, and protein separation. The different cascade utilization alternatives analyse different options for press-pulp utilization, and the LCA results show that the environmental profile of the GBR is highly affected by the utilization of the press-pulp and thus by the choice of conventional product replaced by the press-pulp. Furthermore, scenario analysis of different GBR configurations shows that higher benefits can be achieved by increasing product yields rather than lowering energy consumption. Green biorefining is shown to be an interesting biorefining concept, especially in a Danish context. Biorefining of green biomass is technically feasible and can bring environmental savings, when compared to conventional production methods. However, the savings will be determined by the processing involved in each conversion stage and on the cascade utilization of the different platform products.

Environmental impacts of producing bioethanol and biobased lactic acid from standalone and integrated biorefineries using a consequential and an attributional life cycle assessment approach.

This study evaluates the environmental impacts of biorefinery products using consequential (CLCA) and attributional (ALCA) life cycle assessment (LCA) approaches. Within ALCA, economic allocation method was used to distribute impacts among the main products and the coproducts, whereas within the CLCA system expansion was adopted to avoid allocation. The study seeks to answer the questions (i) what is the environmental impacts of process integration?, and (ii) do CLCA and ALCA lead to different conclusions when applied to biorefinery?. Three biorefinery systems were evaluated and compared: a standalone system producing bioethanol from winter wheat-straw (system A), a standalone system producing biobased lactic acid from alfalfa (system B), and an integrated biorefinery system (system C) combining the two standalone systems and producing both bioethanol and lactic acid. The synergy of the integration was the exchange of useful energy necessary for biomass processing in the two standalone systems. The systems were compared against a common reference flow: "1MJEtOH+1kgLA", which was set on the basis of products delivered by the system C. Function of the reference flow was to provide service of both fuel (bioethanol) at 99.9% concentration (wt. basis) and biochemical (biobased lactic acid) in food industries at 90% purity; both products delivered at biorefinery gate. The environmental impacts of interest were global warming potential (GWP100), eutrophication potential (EP), non-renewable energy (NRE) use and the agricultural land occupation (ALO). Regardless of the LCA approach adopted, system C performed better in most of the impact categories than both standalone systems. The process wise contribution to the obtained environmental impacts also showed similar impact pattern in both approaches. The study also highlighted that the recirculation of intermediate materials, e.g. C5 sugar to boost bioethanol yield and that the use of residual streams in the energy conversion were beneficial for optimizing the system performance.

Environmental life cycle assessment of producing willow, alfalfa and straw from spring barley as feedstocks for bioenergy or biorefinery systems.

The current study aimed at evaluating potential environmental impacts for the production of willow, alfalfa and straw from spring barley as feedstocks for bioenergy or biorefinery systems. A method of Life Cycle Assessment was used to evaluate based on the following impact categories: Global Warming Potential (GWP100), Eutrophication Potential (EP), Non-Renewable Energy (NRE) use, Agricultural Land Occupation (ALO), Potential Freshwater Ecotoxicity (PFWTox) and Soil quality. With regard to the methods, soil organic carbon (SOC) change related to the land occupation was calculated based on the net carbon input to the soil. Freshwater ecotoxicity was calculated using the comparative toxicity units of the active ingredients and their average emission distribution fractions to air and freshwater. Soil quality was based on the change in the SOC stock estimated during the land use transformation and land occupation. Environmental impacts for straw were economically allocated from the impacts obtained for spring barley. The results obtained per ton dry matter showed a lower carbon footprint for willow and alfalfa compared to straw. It was due to higher soil carbon sequestration and lower N2O emissions. Likewise, willow and alfalfa had lower EP than straw. Straw had lowest NRE use compared to other biomasses. PFWTox was lower in willow and alfalfa compared to straw. A critical negative effect on soil quality was found with the spring barley production and hence for straw. Based on the energy output to input ratio, willow performed better than other biomasses. On the basis of carbohydrate content of straw, the equivalent dry matter of alfalfa and willow would be requiring higher. The environmental impacts of the selected biomasses in biorefinery therefore would differ based on the conversion efficiency, e.g. of the carbohydrates in the related biorefinery processes.

Association between fatigue and other motor and non-motor symptoms in Parkinson's disease patients.

Although fatigue is a common non-motor symptom in patients affected by Parkinson's disease (PD), its association with motor and other non-motor symptoms is still largely unclear. We assessed fatigue in PD patients studying the possible association with motor and non-motor symptoms. Eighty-one PD patients were included in the study. The PD Fatigue Scale (PFS) and the Fatigue Severity Scale (FSS) scale were used to measure fatigue. Non-motor symptoms were assessed with the Non-Motor Symptoms Scale (NMSS). Motor impairment was assessed using the modified Hoehn and Yahr (HY) staging and the Unified PD Rating Scale (UPDRS) part-III and IV. Bivariate tests comparing all independent variables between patients with our without fatigue were used. Significant predictors of presence and severity of fatigue were determined with different models of logistic regression analyses. Fatigue severity was significantly higher in female patients. Bivariate test showed significant higher NMSS score in fatigued patients according to PFS (p < 0.00001) and FFS (p < 0.001), while HY was higher only in fatigued patients according to FSS (p < 0.022). Significant correlations between severity of fatigue and HY stage (p < 0.002) and UPDRS-III score (p < 0.001) were found, while, among specific non-motor symptoms, anhedonia presented with the most significant correlation (p < 0.003). Binary logistic regression confirmed NMSS as the main variable predicting presence of fatigue, while HY was significant as predicting variable only in the FSS model. Strongest non-motor symptoms predictors of severity were those included in Domain 3 (mood/anxiety) and Domain 2 (sleep disorders) of the NMSS. A significant increase in severity of fatigue related to the burden of non-motor symptoms (mainly affective and sleep disorders) was observed. Our findings indicate a moderate discrepancy in the ratings of the two fatigue scales, with PFS principally directed towards the burden of non-motor symptoms. Finally, the accurate individuation of the factors underlying fatigue, assessed with the systematic administration of holistic evaluation scales such as the NMSS, might improve current strategies used in the treatment of this disabling condition.

[Treatment of lithiasis with infundibular axis at an acute angle to the calyx entry in PCNL]. / Trattamento della litiasi con asse infundibulare ad angolo acuto rispetto al calice d'ingresso nella PCNL.

INTRODUCTION: In the treatment of pyelo multi calyceal renal lithiasis, although we utilize both rigid and flexible instruments, the greatest challenge when trying to achieve a stone-free status after the procedure with a single access, is represented by the presence of residual caliceal stones difficult to reach for the length of the infundibular system in which they are localized, and major axis of it at an acute angle with respect to the axis of the cannula entrance. We describe our technique of treatment in these cases with no second access. MATERIALS AND METHODS: 55 cases of multiple lithiasis of the lower calyx at the end of PCNL for complex lithiasis were treated with the following technique. Using ultrasound and fluoroscopic guidance a puncture of the calyx adjacent to the cannula was performed. A standard Lubriglide guide (0.038", right or J) was introduced until the renal pelvis. Through a nephroscopic guidance, the guide was retrieved with a clamp and was taken out from the cannula; then the two leaders were locked together by a mosquito-mounted clamp. The guide traction towards the cannula allowed identifying, through the rigid nephroscope, the infundibulum where the lithiasis was located. The infundibulum was sectioned with monopolar electrode and it was possible to access the calyx affected by the lithiasis. RESULTS: In all treated cases it was possible to reach the lithiasis from the single initial percutaneous access and to eliminate them. Small bleedings were dominated by monopolar electrode. The Urography or uro-CT performed after three months showed no residual lithiasis; the infundibulum resumed its morphological characteristics. DISCUSSION: The described technique allows for a complete resolution of the lithiasis with no need of a second access or a retrograde approach, in situations where the combined use of flexible instruments does not allow solving the pathology.

[Endoscopic combined intra renal surgery (ECIRS) in prone position]. / La endoscopic combined intra renal surgery (ECIRS) in posizione prona.

INTRODUCTION: E.C.I.R.S. is currently used in Galdakao-modified supine Valdivia position, since it is thought to be capable of allowing the retrograde approach to the high urinary diseases. Our school developed some good experience in percutaneous procedures in the prone position, with no significant anesthetic complications; we have performed an evaluation of flexible retrograde endoscopy with percutaneous nephrolithotripsy in this position. MATERIALS AND METHODS: 21 patients (14 M - 7 F), with a mean age 44.5 years (range 27-62), with complex urolithiasis, underwent percutaneous nephrolithotripsy associated with flexible retrograde endoscopy (E.C.I.R.S.) in the prone position. The technique has followed these steps: patient's positioning in the prone position; flexible cystoscopy and insertion of guide 0.038" stiff Lubriglide flexible tip; ureteral sheath 11/13 Ch until the lumbar ureter; fixing the end of the sheath to the surgical drape with sutures or surgical instrument; catheter Nelaton transurethral 10 Ch to the side of the sheath; renal puncture and routine procedure for the nephrolithotripsy assisted by the flexible instrumentation by retrograde approach. The procedure ended with the application of a Re-entry Malecot nephrostomy tube (Boston Scientific). RESULTS: The ureteral sheath was easily applicable in the prone position for all patients, with no difference between males and females; its presence made it easier to enter and the progression of the flexible instrument by retrograde approach. Idem come sopra. There was no lengthening of operative time associated with retrograde instrumentation. The "stone free" status was obtained in 100% of cases. There were no complications. DISCUSSION: The stabilized ureteral sheath allows for the comfortable and secure combined endorenal prone procedure, with flexible instruments both in men and women, through a safe and effective technique.

[Laparoscopic transmesocolic pyeloplasty: our technical notes on the application of intrasurgical ureteral DJ catheter]. / Pieloplastica laparoscopica transmesocolica: nostre note di tecnica nell'applicazione del catetere ureterale a dj intraoperatorio.

INTRODUCTION: The ureteral stent used for laparoscopic pyeloplasty can be placed pre-surgically, intra-surgically or post-surgically. The intra-surgical application can be carried out by anterograde or retrograde techniques. MATERIALS AND METHODS: 23 patients affected by pelviureteric junction disease (14 males, 9 females), aged between 10 and 55 years, underwent laparoscopic pyeloplasty with Anderson Hynes technique. No patient had a pre-surgery DJ ureteral catheter. Surgery was performed on lateral decubitus with external genitals. A sterile field including a flexible cystoscope was prepared to apply the ureteral catheter. Pyeloplasty was performed. After placing the first 4 ureteropelvic anastomosis stitches, flexible cystoscopy was performed by applying a leading probe 0.038 or 0.035 stiff Lubriglide flexible straight tip, depending on the ureter caliber. A ureteral catheter 6 or 4.8 Ch was used. The guide was followed by laparoscope until the renal pelvis or superior renal calices were reached. After extracting the cystoscope, the ureteral catheter was inserted with a suitable pusher up to the pelvis. After guide extraction, J modeling was performed. The time elapsed from the beginning of cystoscopy until the end of the procedure was calculated. RESULTS: The procedure was easily performed in all patients. The application time varied between 5 and 8 minutes for males, and from 6 to 10 minutes for females. The DJ catheter in laparoscopic pyeloplasty was applied by retrograde way. An alternative is the laparoscopic access or application in a previous moment with the need of two different surgical fields. This provides a reasonable execution time, the only difficulty being the finding of the external urethral meatus. CONCLUSIONS: The intra-surgical application of DJ ureteral stent is a good alternative to the supine anterograde or retrograde technique.

[Laparoscopic ureteral reimplantation surgery according to Lich-Gregoir]. / Reimpianto ureterale secondo Gregoir-Lich per via laparoscopica.

INTRODUCTION: Terminal ureteral stenosis can occur as a consequence of gynecological diseases or surgical treatment of simple or radical hysterectomy and pelvic endometriosis. MATERIALS AND METHODS: We evaluated 5 patients aged between 30 and 52 years, who underwent ureterocystoneostomy for ureteral stenosis due to several factors: 2 cases of pelvic endometriosis; 2 cases of surgery treatment of pelvic endometriosis, and 1 case of simple hysterectomy. Patients were placed supine in Trendelemburg position of about 30°. After pneumoperitoneum induction, the following equipment was introduced through four different laparoscopic accesses: the optic tool into the umbilicus access, 5-mm operative accesses on the lesion side, and one of 10-11 mm in the contralateral site. Once we incised the peritoneum and isolated the distal ureter until the stenotic tract, we proceeded with the dissection, performing a 2 cm serum-muscle incision of the bladder, showing the mucosa after previous distension with 200 mL of saline. A little operculum in the mucosa was created by a spatula. After applying a DJ ureteral catheter with the distal end introduced into the bladder, the direct ureteral-vesical anastomosis was made. The application of serum-detrusor sutures next to the ureter created the antireflux barrier. The peritoneum was closed. RESULTS: Surgery was performed by laparoscopy without conversion into open surgery. Average performing time was 205 min. Clinical stay was 5 days and DJ ureteral catheter was removed after 3 weeks following cystography and absence of spillage around the bladder. The ultrasound controls performed after three and six months did not show any complication. CONCLUSIONS: Laparoscopy is a valid alternative to open surgery, also yielding better esthetic results, particularly in cases where the classical approach is difficult to perform, as for example in obese patients.

[Use of TachoSil in laparoscopic enucleoresection of renal masses smaller than 4 cm: our preliminary experience of 41 cases]. / Utilizzo di Tachosil nell'enucleoresezione renale laparoscopica di masse inferiori a 4 cm: la nostra esperienza preliminare di 41 casi.

INTRODUCTION: In nephron-sparing surgery the use of new and various hemostatic materials has provided a significant support in the control of intraoperative hemostasis of resection bed. Objective of this study is to demonstrate the use of hemostatic material TachoSil in laparoscopic treatment of renal masses <4 cm. MATERIALS AND METHODS: 41 patients underwent laparoscopic renal enucleoresection. In all patients one or more hemostatic TachoSil sponges were used, affixed to the bed of resection; we retrospectively evaluated the efficacy and safety of this technique. Transperitoneal access in 39 patients with antero-lateral mass and retroperitoneoscopic access in 2 patients with middle-posterior mass. After performing a warm ischemia, we proceeded to mass enucleoresection by cold blade, and to hemostasis control by suturing open vessels on the resection bed with "central suturing" technique. After unclamping the renal artery, one or more hemostatic sponges of TachoSil were always used (fibrinogen and human thrombin) affixed to the bed section. RESULTS: No significant variations of Hb, BUN and Crs. 3 cases (6.9% of renal units) of intraoperative hemorrhage requesting blood transfusion, 2 cases (4.6% of renal units) of urinary leakage at low pressure, treated conservatively with retrograde application of ureteral stent DJ for 21 days; 2 patients underwent new laparoscopy and suture. The mean time to hemostasis, evaluated in terms of the absence of macroscopic intraoperative bleeding after the application of TachoSil, was 5.5 (3-16) minutes. Average hospital stay: 5.5 (4-11) days. FOLLOW-UP: 37.6 (5-84) months. DISCUSSION: The control of hemostasis is the key problem inherent to laparoscopic technique and can be approached using hemostatic agents. Currently hemostatic agents such as TachoSil ® are used increasingly as an adjuvant agent in the control of bleeding, having an excellent application in laparoscopic renal enucleoresection, and proving safe and effective in the treatment of tumors below 4 cm.

[The Endovision technique in renal percutaneous lithotripsy]. / L'approccio Endovision nella litotrissia percutanea endorenale.

INTRODUCTION: In order to achieve a safer percutaneous access to the kidney, even if not systematically, it is possible to combine the use of eco-fluoro-guided puncture with the endoscopic retrograde vision through flexible ureteroscopy. Our experience has been conducted in order to standardize the technique and highlight advantages and limitations. 
 MATERIALS AND METHODS: 26 patients (15 M-11 F), mean age 46 years, underwent flexible ureterorenoscopy as first percutaneous access for pyelic or pyelocaliceal stones.
20 cases were conducted in the prone and 6 in the supine position. 
We proceeded with the study of the caliceal topography and the choice of the calyx suitable for puncture, studying the orientation of the main axis of the papilla of the lower or middle group. Leaving the endoscopic instrument in place, we proceeded with the contrast injection and the eco-fluoro-guided puncture. The retrograde instrument followed the puncture and access dilatation.
 RESULTS: In 16 cases we identified a papilla of the lower caliceal group with a correct orientation for the renal puncture; in the other 10, we chose a papilla of the middle group, because it was more favorable. In 10 cases the puncture was made at the center of the papilla with its axis in favor; in 16 it was necessary to correct the puncture because the needle had penetrated the fornix (no. 14) or had punctured the other side of the calyx (no. 2). 
In 10 cases the puncture correction caused some bleeding, which required a careful washing in order to clear the field of vision and repeat the procedure; in other 6 cases, this was not possible: the Endovision procedure was interrupted and completed according to the conventional method. There was no difference in technique between the supine and the prone position.
 DISCUSSION: It is not always likely to find a papilla of lower calyx suitable to correct puncture.
The Endovision technique is related to an inevitably blind moment linked to the displacement of the kidney, which is not followed by the flexible instrument, and to the limitations related to the visibility. The technique can be used both in the prone and supine position; chances are that it might not always be completed.

[Endoscopic prostate resection by bipolar gyrus resector for prostates over 80 ml: our experience after a 12-month follow-up]. / La resezione endoscopica con resettore bipolare gyrus nelle ghiandole di volume superiore a 80 ml: nostra esperienza a 12 mesi di follow-up.

INTRODUCTION: The open surgery approach is the gold standard for the treatment of prostatic adenoma with a volume over 80 mL. PATIENTS AND METHODS: We studied 180 patients from June 2004 to June 2011, affected by prostatic adenoma >80 mL, and who underwent endoscopic resection performed with bipolar technique by a single operator. We considered the following data: surgery duration, bleeding, absorption of irrigating fluids, resected tissue quantity, clinical stay, and catheterization time. Resections up to the surgical capsule were performed with bipolar Gyrus resector and the fragments were collected with prostate Ellik-type conveyor. Next step was the positioning of the bladder catheter with cystoclysis. We evaluated early and late complications and performed clinical reassessment of the patients at 1, 3, 6 and 12 months. RESULTS: Surgery average time was 118 min. The average resected tissue volume was 92 g. The post-surgery hemoglobin was 13.2 g/dL. In 15 patients a revision of the lodge was performed within 24 hours after resection; no blood transfusions were performed. The catheter was removed after 3.2 days and the average recovery time was 4 days. There were eight cases of cicatricial stenosis of the bladder neck treated with endoscopic laparotomy. There were no cases of post-TURP syndrome. The IPSS parameters varied from 20.7 to 3.8, the IIEF5 from 19.3 to 21.2. The average QoL decreased from 4 to 1.5, Qmax from 22.2 7.7 mL/sec. The total PSA values decreased from 6.39 ng/mL to 1.0 ng/mL. CONCLUSIONS: TURP for prostatic adenomas greater than 80 mL in volume, is a valid alternative in terms of efficacy and safety to open surgery, considered the gold standard treatment.