Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study.

OBJECTIVE: To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting. METHODS: We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests. RESULTS: After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates. CONCLUSION: The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.

Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation.

Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.

Managing Patients with Prostate Cancer During COVID-19 Pandemic: The Experience of a High-Volume Robotic Surgery Center.

Objectives: To report our experience and lessons learned as high-volume center of robotic surgery managing patients with prostate cancer since the beginning of the COVID-19 pandemic in our center. Materials and Methods: We described some critical changes in our routine to minimize the COVID infection among patients and health care workers. From March 1 to May 25, 2020, we described our actions and surgical outcomes of patients treated in our center during the pandemic. Results: Preventing hospital visits, we implemented some modifications in our office routine in terms of patient appointment, follow-up, and management of nonsurgical candidates. In this period, 147 patients underwent robot-assisted radical prostatectomy (RARP) without intraoperative complications. The median operative time and blood loss were 91 minutes (interquartile range [IQR] = 25) and 50 mL (IQR = 50), respectively. The median hospitalization time was 15.8 hours (IQR = 2.5). None of the patients of our study had COVID in the postoperative follow-up, and only two patients were rescheduled due to a positive rapid COVID test 1 day before surgery. The final pathology described 10 patients (6.8%) Grade Group (GrGp) 1, 34 (23.1%) GrGp 2, 31 (21%) GrGp 3, 16 (10.8%) GrGp 4, 37 (25.3%) GrGp 5, and 19 (13%) with deferred Gleason. Two patients, COVID negative, were readmitted due to infected lymphocele managed with antibiotic and Interventional Radiology drainage. Conclusion: Our experience managing patients with prostate cancer during the COVID-19 pandemic showed that changing the office routine, stratifying the patients according to the National Comprehensive Cancer Network (NCCN) risk, and adopting COVID-based criteria to select patients for surgery are necessary actions to maintain the best quality of treatment and minimize the viral infection among our oncological patients. In our routine, the RARP during the COVID pandemic is safe and feasible for patients and health care workers if the necessary precautions described in this article are taken.

Alternative and Natural Therapies for Acute Lung Injury and Acute Respiratory Distress Syndrome.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a complex clinical syndrome characterized by acute inflammation, microvascular damage, and increased pulmonary vascular and epithelial permeability, frequently resulting in acute respiratory failure and death. Current best practice for ARDS involves "lung-protective ventilation," which entails low tidal volumes and limiting the plateau pressures in mechanically ventilated patients. Although considerable progress has been made in understanding the pathogenesis of ARDS, little progress has been made in the development of specific therapies to combat injury and inflammation. AREAS COVERED: In recent years, several natural products have been studied in experimental models and have been shown to inhibit multiple inflammatory pathways associated with acute lung injury and ARDS at a molecular level. Because of the pleiotropic effects of these agents, many of them also activate antioxidant pathways through nuclear factor erythroid-related factor 2, thereby targeting multiple pathways. Several of these agents are prescribed for treatment of inflammatory conditions in the Asian subcontinent and have shown to be relatively safe. EXPERT COMMENTARY: Here we review natural remedies shown to attenuate lung injury and inflammation in experimental models. Translational human studies in patients with ARDS may facilitate treatment of this devastating disease.

The role of 68Ga-PSMA PET/CT scan in biochemical recurrence after primary treatment for prostate cancer: a systematic review of the literature.

INTRODUCTION: Recurrence after primary treatment of prostate cancer is one of the major challenges facing urologists. Biochemical recurrence is not rare and occurs in up to one third of the patients undergoing radical prostatectomy. Management of biochemical recurrence is tailored according to the site and the burden of recurrence. Therefore, developing an imaging technique to early detect recurrent lesions represents an urgent need. Positron emission tomography (PET) of 68Ga-labelled prostate-specific membrane antigen (68Ga-PSMA) is an emerging imaging modality that seems to be a promising tool with capability to localize recurrent prostate cancer. A systematic review of literature was done to evaluate the role of 68Ga-PSMA PET/CT scan in patients with recurrent prostate cancer after primary radical treatment. EVIDENCE ACQUISITION: A systematic and comprehensive review of literature was performed in September 2017 analyzing the MEDLINE and Cochrane Library following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The following key terms were used for the search "PSMA," "prostate-specific membrane antigen," "positron emission tomography," "PET," "recurrent," "prostate cancer," "prostate neoplasm," "prostate malignancy," and "68Ga." Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. EVIDENCE SYNTHESIS: Thirty-seven articles met our inclusion criteria and were included in the analysis of this systematic review. Of the 37 articles selected for analysis only four studies were prospective. The overall detection rate of 68Ga-PSMA PET scan ranged from 47% up to 96.6%. The main advantage of this imaging technique is its relatively high detection rates at low serum PSA levels below 0.5 ng/mL (ranging from 11.1% to 75%). Higher serum PSA level was strongly associated with increased positivity on 68Ga-PSMA PET scan. 68Ga-PSMA PET scan was found superior to conventional imaging techniques (CT and MRI) in this setting of patients and even it seems to outperform choline-based PET scan. This technique provided significant changes in the therapeutic management of 28.6-87.1% of patients. CONCLUSIONS: After biochemical recurrence, the primary goal is to locate the recurrent lesions' site. 68Ga-PSMA PET/CT seems to be effective in identifying recurrence localization also for very low levels of PSA (<0.5 ng/mL) thus permitting to choose the best therapeutic strategy as early as possible. However, data available cannot be considered exhaustive and prospective randomized trials are needed.

Formulation Studies of Solid Self-Emulsifying Drug Delivery System of Ivermectin.

BACKGROUND: The suggested dose of ivermectin is 300 µG/kg/day for onchocerciasis but it has low water solubility and poor oral bioavailability. AIM: To prepare and evaluate a solid lipid-based self-emulsifying drug delivery system of ivermectin. MATERIALS AND METHODS: Based on supersaturated solubility study, oil, surfactant, and co-surfactant were selected. On the basis of ternary phase diagrams and simplex-lattice design, self-emulsifying, drug delivery formulations had been developed and optimized. Ivermectin-excipients compatibility studies were performed using differential scanning calorimetry and Fourier transform infrared spectroscopy. Solid self-emulsifying drug delivery formulation was formulated from the optimized batch by surface assimilation method and filled into hard gelatin capsules. In vitro release rate and in vivo pharmacokinetic parameters of ivermectin from the capsules were determined. Two-tailed paired t-test/Dunnett multiple comparison tests were performed for in vivo pharmacokinetic parameter at 95 % of confidence level. RESULTS: Soybeans oil, tween 80, and span 80 were selected as oil, surfactant, and co-surfactant respectively. The ternary diagrams were shown the maximum area for emulsion in 1:2 surfactant/co-surfactant ratio. The optimized batch had found with 30 mg ivermectin, 6.17 g soybeans oil, 0.30 g tween 80, and 3.50 g span 80. All differential scanning calorimetry and Fourier transform infrared characteristic peaks of the optimized formulation were identical with that of pure ivermectin. The area under the curve of ivermectin from the capsule was about two-fold higher than that of ivermectin suspension. CONCLUSIONS: Solid self-emulsifying drug delivery system was an effective oral solid dosage form to improve the oral bioavailability of ivermectin.

Isolation, development and identification of salt-tolerant bacterial consortium from crude-oil-contaminated soil for degradation of di-azo dye Reactive Blue 220.

The objective of this study was development and characterization of a halophilic bacterial consortium for rapid decolorization and degradation of a wide range of dyes and their mixtures. The 16S rRNA gene analysis of developed halophilic consortium VN.1 showed that the bacterial consortium contained six bacterial strains, which were identified as Pseudomonas fluorescens HM480360, Enterobacter aerogenes HM480361, Shewanella sp. HM589853, Arthrobacter nicotianae HM480363, Bacillus beijingensis HM480362 and Pseudomonas aeruginosa JQ659549. Halophilic consortium VN.1 was able to decolorize up to 2,500 mg/L RB220 with >85% chemical oxygen demand (COD) reduction under static condition at 30 °C and pH 8.0 in the presence of 7% NaCl. VN.1 also exhibited more than 85% COD reduction with >25 mg/(L h) rate of decolorization in the case of different reactive dye mixtures. We propose the symmetric cleavage of RB220 using Fourier transform infrared, high-performance liquid chromatography (HPLC), nuclear magnetic resonance and gas chromatography-mass spectrometry analysis, and confirmed the formation of sodium-4-aminobenzenesulfonate, sodium-6-aminonepthalenesulfonate, and sodiumbenzene/nepthalenesulfonate. Toxicity studies confirm that the biodegraded products of RB220 effluent stimulate the growth of plants as well as the bacterial community responsible for soil fertility.

Curcumin and lung cancer--a review.

Curcumin (diferuloylmethane) is the most important component of the spice turmeric and is derived from the rhizome of the East Indian plant Curcuma longa. Curcumin has been used extensively in Ayurvedic medicine for centuries, as it is nontoxic and has a variety of therapeutic properties including antioxidant, analgesic, anti-inflammatory, and antiseptic activities. Recently, curcumin has been widely studied for its anticancer properties via its effects on a variety of biological pathways involved in apoptosis, tumor proliferation, chemo- and radiotherapy sensitization, tumor invasion, and metastases. Curcumin can be an effective adjunct in treating solid organ tumors due to its properties of regulating oncogenes like p53, egr-1, c-myc, bcl-XL, etc.; transcription factors like NF-kB, STAT-3, and AP-1; protein kinases like MAPK; and enzymes like COX and LOX. Lung cancer is the most common malignancy worldwide and a leading cause of cancer-related deaths. Seventy-five percent of lung cancer presents at an advanced stage where the existing treatment is not very effective and may result in tremendous patient morbidity. As a result, there is a significant interest in developing adjunctive chemotherapies to augment currently available treatment protocols, which may allow decreased side effects and toxicity without compromising therapeutic efficacy. Curcumin is one such potential candidate, and this review presents an overview of the current in vitro and in vivo studies of curcumin in lung cancer.

The outcome of treating ESBL infections with carbapenems vs. non carbapenem antimicrobials.

BACKGROUND: In India where the prevalence of extended spectrum beta lactamase (ESBL) producing organisms among gram negative organisms is 60-70% and Ertapenem was unavailable at the beginning of this study, exclusive use of Group 2 Carbapenems (Imipenem and Meropenem) for treatment raises issues of cost and development of resistance. Therefore the role of non-Carbapenem alternatives, chiefly Betalactam + Betalactamase inhibitors (BL-BLI) was explored in this prospective observational study at a private tertiary care teaching hospital. PATIENTS AND METHODS: 522 consecutive in door patients from the period between June 2006 to March 2007and June 2008 to December 2008, who had true infections with ESBL producing organisms were enrolled in the study. Antimicrobials were prescribed or changed by the treating physicians on the basis of the nature and severity of infection, the susceptibility of the organism and the affordability of the patient. Patients who received a Carbapenem at any time during treatment were considered in the Carbapenem group. Those who never received a Carbapenem at any time during treatment were considered in the non-Carbapenem group. RESULTS: Of the 522 infections, 287 were urinary tract infections, 60 were skin structure infections, 60 were bacteremias, 55 were hospital acquired pneumonias, 31 were intra-abdominal infections and 29 were other infections. There were 351 E. coli, 119 K. pneumoniae, 23 K. oxytoca, 16 Enterobacter aerogenes, 5 Kozoanae, 4 Enterobacter agglomerans, 3 Citrobacter freundi, 1 E. cloacae, 1 Enterobacterspp. and 1 Morgenella morganii isolates. Clinical outcomes were available for 486 patients. 339 patients who were in the non-Carbapenem group and who might have had less serious infections had a clinical success rate of 79.6%. 147 patients who were in the Carbapenem group and who might have had more serious infections had a clinical success rate of 85.71%. CONCLUSIONS: It is possible to successfully treat at least the less serious infections due to ESBL producing gram negative organisms with non-Carbapenem antimicrobials. This will not compromise outcomes but will likely result in restricting the use of Carbapenems which may help preserve their efficacy against increasingly resistant organisms.

Relative risk factors for requirement of blood transfusion after total hip arthroplasty.

One thousand thirty-five total hip arthroplasty (THA) cases were retrospectively reviewed, and the number and type (autologous and allogenic) of postoperative units of blood transfused were analyzed with respect to pre-, intra-, and postoperative variables. The most significant and consistent predictors of a blood transfusion after THA were advanced age and the use of low-molecular-weight heparin for deep venous thrombosis prophylaxis. Our recommendations for predonation are 1 unit for THA patients younger than 75 years if hemoglobin is 130 g/dL or greater and 2 units or a combination of 1 unit of predonated blood and 1 unit of directed or banked blood for THA patients older than 75 years.

Risks associated with blood transfusion after total knee arthroplasty.

A retrospective study of 1,402 patients who underwent primary total knee arthroplasty (TKA) (1,194 unilateral, 208 bilateral) was performed. The strongest predictors for allogenic transfusion after surgery were advancing age (P<.001), low preoperative hemoglobin (P<.001), and the use of low-molecular-weight heparin postoperatively (P<.01). Pre-donation of 1 unit of autologous blood before TKA decreased the allogenic transfusion rate from a baseline of 38% to 11%, whereas pre-donating 2 units lowered the rate of breakthrough transfusion of allogenic blood to 7%. A patient with a preoperative hemoglobin >150 g/L or who is younger than age 65 with a preoperative hemoglobin >130 g/L may not benefit from pre-donation, and a high rate of wastage may result.

Estimation of acute blood loss in the anticoagulated rabbit model using 3 modalities of radio frequency energy ablation.

PURPOSE: An anticoagulated animal model was tested to evaluate estimated acute blood loss (EABL) following tissue ablation with 3 modalities of radio frequency (RF) thermal energy. MATERIALS AND METHODS: Four groups of randomly divided rabbits were established. Group 1 (3 control and 3 anticoagulated rabbits) underwent sham treatment (noRF), group 2 (2 control and 7 anticoagulated) received single probe dry RF (dRF) (475 KHz and 5 W for 2 minutes), group 3 (2 control and 7 anticoagulated) received single probe wet RF (wRF) (475 KHz with 14.6% hypertonic saline at 50 W for 40 seconds) and group 4 (3 control and 7 anticoagulated) was treated with vapor RF (vRF) (0.9% normal saline for 10 seconds). Oral warfarin sodium was the anticoagulant. Following a midline incision ablation was performed on the left kidney and liver. Pre-weighed gauze pads were used to collect EABL for a 5-minute observation period after needle probe removal. Temperature data were recorded from the right kidney using fiberoptic thermocouples. Lesions were grossly inspected and measured. RESULTS: Anticoagulation resulted in super anticoagulated animals with an average prothrombin time of almost 140 seconds. EABL was the least from the ablated left kidney for vRF (50 mg), followed by wRF (260 mg), dRF (390 mg) and noRF (1,800 mg). EABL was the least from the liver for vRF (10 mg), followed by wRF (470 mg), dRF (1,260 mg) and noRF (2,680 mg). A greater percent of total ablative time at 10 mm was spent at greater than 50C during wRF and vRF. Measured ablative lesions size was largest following vRF ablation. CONCLUSIONS: The thermal coagulative effects of RF ablation resulted in less bleeding compared with controls in this orally anticoagulated animal model. The novel RF modality vRF is introduced.