RESUMEN
PURPOSE: To determine whether the early apical release (EAR) technique for holmium laser enucleation of the prostate (HOLEP) is associated with improved perioperative outcomes compared to the En-bloc no touch (EBNT) technique. METHODS: Consecutive men treated with HOLEP by a single surgeon from August 2018 to March 2021 were identified. Beginning in June 2021 all procedures were performed using the EAR technique, and these were compared to the preceding cases done with the EBNT technique. Intraoperative outcomes included operative time, need for open conversion, enucleation efficiency (tissue removed per minute of OR time), and enucleation ratio (tissue removed relative to preoperative gland size on imaging). Postoperative outcomes included catheter reinsertion, blood transfusion, and complications classified by the Clavien-Dindo scale. RESULTS: We identified 801 men, including 571 (71%) treated with EBNT and 230 (29%) with EAR. Median preoperative characteristics were similar between groups. The EAR approach was associated with significantly longer mean operating room time, 100.5 min versus 91.9 min, p = 0.003. However, EAR patients had a much lower rate of conversion to open cystotomy (0.43% versus 3.0%). There were no significant differences in rate of catheter reinsertion or perioperative complications between groups (p > 0.05). CONCLUSION: EAR technique by an experienced HoLEP surgeon resulted in longer operative times, potentially reflecting an initial learning curve, but essentially eliminated the need for open cystotomy. Perioperative results including catheter reinsertion rate and bleeding complications were similar between the two cohorts. These data support continued use of the EAR technique for HOLEP to minimize risk of open conversion.
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Terapia por Láser , Láseres de Estado Sólido , Hiperplasia Prostática , Cirujanos , Resección Transuretral de la Próstata , Masculino , Humanos , Próstata/cirugía , Holmio , Resección Transuretral de la Próstata/métodos , Hiperplasia Prostática/cirugía , Hiperplasia Prostática/complicaciones , Estudios de Cohortes , Láseres de Estado Sólido/uso terapéutico , Terapia por Láser/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: To investigate the use of a high-arginine immunonutrient supplement prior to radical cystectomy for bladder cancer. MATERIALS AND METHODS: We recruited 40 patients to consume a total of four high-arginine immunonutrient shakes per day for 5 days prior to radical cystectomy. The primary outcome measures were safety, tolerability and adherence to the supplementation regimen. Ninety-day postoperative outcomes were also compared between supplemented patients and a cohort of 104 prospectively identified non-supplemented radical cystectomy patients. Multivariable logistic regression models were used to compare overall complications, infectious complications, and readmission rates between groups. RESULTS: There were no serious adverse events during supplementation. Four patients (10%) stopped supplementation due to nausea (n = 2) and bloating (n = 2). Thirty-three patients (83%) consumed all prescribed shakes. Immunonutrient supplementation was not significantly associated with overall complications (adjusted odds ratio [OR] 1.08; 95% confidence interval [CI] 0.50-2.33), infectious complications (OR 1.23; 95% CI 0.49-3.07), or readmissions (OR 1.48; 95% CI 0.62-3.51) on multivariable analyses. CONCLUSIONS: Preoperative supplementation with a high-arginine immunonutrient shake was safe and well tolerated prior to radical cystectomy. Contrary to prior reports, immunonutrient supplementation was not associated with lower postoperative infectious complications in this cohort, perhaps owing to the 5 day supplementation period. Further study is needed to identify the optimal immunonutrient supplement regimen for radical cystectomy patients.
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Arginina/uso terapéutico , Cistectomía , Complicaciones Posoperatorias/microbiología , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios/métodos , Neoplasias de la Vejiga Urinaria/cirugía , Anciano , Cistectomía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Complicaciones Posoperatorias/inmunologíaRESUMEN
BACKGROUND AND OBJECTIVES: To evaluate whether urologic procedures during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) are associated with adverse postoperative outcomes. METHODS: We identified patients who underwent CRS-HIPEC at our institution from 2001 to 2012 and compared outcomes between operations that did and did not include a urologic procedure. RESULTS: A total of 938 CRS-HIPEC procedures were performed, 71 of which included a urologic intervention. Urologic interventions were associated with longer operative times (547 vs. 459 min, P < 0.001) and greater length of stay (15 vs. 12 days, P = 0.003). Major complications (Clavien III and IV) were more common in the urologic group (31% vs. 20%, P = 0.028). On multivariable analysis, urologic procedures were associated with a low anterior resection (OR: 2.25, 95%CI 1.07-4.74, P = 0.033) and a greater number of enteric anastomoses (OR: 1.83, 95%CI 1.31-2.56, P < 0.001). At a median follow up of 17 months (IQR 5.6-35 months), addition of a urologic procedure did not significantly impact overall survival for appendiceal or colorectal cancers. CONCLUSION: Urologic surgery at the time of CRS-HIPEC is associated with longer operative times, length of stay and increased risk of major complications, but not with decreased overall survival. J. Surg. Oncol. 2016;113:218-222. © 2016 Wiley Periodicals, Inc.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias del Apéndice/terapia , Quimioterapia del Cáncer por Perfusión Regional/métodos , Neoplasias Colorrectales/terapia , Procedimientos Quirúrgicos de Citorreducción , Hipertermia Inducida , Neoplasias Peritoneales/terapia , Procedimientos Quirúrgicos Urológicos/efectos adversos , Adulto , Anciano , Neoplasias del Apéndice/mortalidad , Neoplasias del Apéndice/patología , Neoplasias del Apéndice/cirugía , Quimioterapia Adyuvante/métodos , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Tempo Operativo , Neoplasias Peritoneales/mortalidad , Neoplasias Peritoneales/secundario , Neoplasias Peritoneales/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
In α-chloralose anesthetized cats, we examined the role of opioid receptor (OR) subtypes (µ, κ, and δ) in tibial nerve stimulation (TNS)-induced inhibition of bladder overactivity elicited by intravesical infusion of 0.25% acetic acid (AA). The sensitivity of TNS inhibition to cumulative i.v. doses of selective OR antagonists (cyprodime for µ, nor-binaltorphimine for κ, or naltrindole for δ ORs) was tested. Naloxone (1 mg/kg, i.v., an antagonist for µ, κ, and δ ORs) was administered at the end of each experiment. AA caused bladder overactivity and significantly (P < 0.01) reduced bladder capacity to 21.1% ± 2.6% of the saline control. TNS at 2 or 4 times threshold (T) intensity for inducing toe movement significantly (P < 0.01) restored bladder capacity to 52.9% ± 3.6% or 57.4% ± 4.6% of control, respectively. Cyprodime (0.3-1.0 mg/kg) completely removed TNS inhibition without changing AA control capacity. Nor-binaltorphimine (3-10 mg/kg) also completely reversed TNS inhibition and significantly (P < 0.05) increased AA control capacity. Naltrindole (1-10 mg/kg) reduced (P < 0.05) TNS inhibition but significantly (P < 0.05) increased AA control capacity. Naloxone (1 mg/kg) had no effect in cyprodime pretreated cats, but it reversed the nor-binaltorphimine-induced increase in bladder capacity and eliminated the TNS inhibition remaining in naltrindole pretreated cats. These results indicate a major role of µ and κ ORs in TNS inhibition, whereas δ ORs play a minor role. Meanwhile, κ and δ ORs also have an excitatory role in irritation-induced bladder overactivity.
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Receptores Opioides delta/metabolismo , Receptores Opioides kappa/metabolismo , Receptores Opioides mu/metabolismo , Nervio Tibial , Estimulación Eléctrica Transcutánea del Nervio , Vejiga Urinaria Hiperactiva/terapia , Ácido Acético , Animales , Gatos , Femenino , Masculino , Morfinanos/farmacología , Morfinanos/uso terapéutico , Naloxona/farmacología , Naltrexona/análogos & derivados , Naltrexona/farmacología , Naltrexona/uso terapéutico , Receptores Opioides delta/antagonistas & inhibidores , Receptores Opioides kappa/antagonistas & inhibidores , Receptores Opioides mu/antagonistas & inhibidores , Vejiga Urinaria Hiperactiva/inducido químicamente , Vejiga Urinaria Hiperactiva/metabolismo , Vejiga Urinaria Hiperactiva/fisiopatologíaRESUMEN
OBJECTIVE: To determine whether transfusion using the Cell Saver system is associated with inferior outcomes in patients undergoing open partial nephrectomy. METHODS: All patients who underwent open partial nephrectomy by a single surgeon (BJD) from August 2008 to April 2015 were retrospectively identified. Operations were grouped and compared according to whether they included a transfusion using the Cell Saver intraoperative cell salvage system. RESULTS: Sixty-nine open partial nephrectomies in 67 patients were identified. Thirty-three procedures (48%) included a Cell Saver transfusion. Most tumors were clear cell renal cell carcinoma (62%) and stage T1a (68%). There were no significant differences between groups for any measured clinical or pathologic characteristics. Operations including a Cell Saver transfusion were longer (141 vs 108 minutes, P <.001), had significantly greater blood loss (600 vs 200 mL, P <.001), and had longer median renal ischemia times (15 vs 10 minutes, P = .03). There were no significant differences in postoperative complication rate (21% vs 17%, P = .83) or median length of hospital stay (3 vs 3 days, P = .09). At a median follow-up of 23 months (interquartile range: 8-42 months), 1 patient in the non-Cell Saver transfusion group had cancer recurrence. There was no metastatic progression or cancer-specific mortality in either group. CONCLUSION: Cell Saver transfusion during open partial nephrectomy was not associated with inferior outcomes with short-term follow-up, and no patients developed metastatic disease.