Initial experiences with the Hemopatch® as a hemostatic agent in zero-ischemia partial nephrectomy.

PURPOSE: Nephron-sparing surgery (NSS) is the gold standard treatment for resectable renal tumors. In the last decade, laparoscopic partial nephrectomy (LPN) has evolved in technical, surgical and oncological aspects and is an accepted treatment option for local-stage renal tumors. Improvements in not only surgical techniques, but also potent hemostats have encouraged this evolution. Here, we report our initial experiences with a new hemostatic agent, Hemopatch(®) (polyethylene glycol-coated collagen patch, Baxter), in zero-ischemia LPN. METHODS: Seven patients with confirmed renal masses were enrolled and subjected to zero-ischemia LPN. In all cases, Hemopatch(®) was applied to the tumor resection site after suturing of the renal parenchyma. The following clinical data were captured for analysis: staging information, PADUA and RENAL nephrometry scores, operation time, blood loss, complications, pathology and hospitalization length. RESULTS: The median tumor size was 30.0 mm (range 9.5-72). The median PADUA and RENAL nephrometry scores were 6 (range 6-7) and 4 (range 4-6), respectively. All LPNs were performed with the zero-ischemia technique. In six of the seven patients, parenchymal suturing of the resection site was performed. No uncontrolled bleeding was observed. The median operation duration was 139 min (range 103-194), the median blood loss was 325 cc (range 50-700) and the median hospitalization length was 6 days (range 4-7). Hemopatch(®) provided sufficient hemostasis in all cases. No postoperative complications were observed. CONCLUSIONS: Although this study is limited to a small set of initial experiences with Hemopatch(®) in LPN, it proves the feasibility and reliability of this new hemostat. Following further evaluation in prospective randomized comparative studies, Hemopatch(®) might represent a promising tool in NSS.

[Update on the zoonotic potential of Chlamydia]. / Update zum Zoonosepotential von Chlamydien.

INTRODUCTION: Knowledge of the obligate intracellular bacteria from the Chlamydiaceae family has increased significantly in recent years. Not only new chlamydia species, such as Chlamydia avium or C. buteonis in birds have been described, but also known chlamydia in new host species, such as C. psittaci in horses. This review article provides an up-to-date overview of the zoonotic potential of C. psittaci, C. abortus, C. caviae and C. felis and summarizes current findings on other chlamydia species in different animal species; supplemented by information on optimal sampling and pathogen detection.

INTRODUCTION: Les connaissances sur les bactéries intracellulaires obligatoires de la famille des Chlamydiaceae ont considérablement augmenté ces dernières années. Non seulement de nouvelles espèces de Chlamydies, telles que Chlamydia avium ou C. buteonis chez les oiseaux, ont été décrites, mais également des Chlamydies déjà connues ont été mises en évidence chez de nouvelles espèces hôtes, telles que C. psittaci chez les chevaux. Cet article de synthèse fournit une vue d'ensemble actualisée du potentiel zoonotique de C. psittaci, C. abortus, C. caviae et C. felis et résume les connaissances actuelles sur d'autres espèces de Chlamydies chez différentes espèces animales ; il est complété par des informations sur l'échantillonnage optimal et la détection des agents pathogènes.

Longitudinal increase in the detection rate of Mycobacterium chimaera in heater-cooler device-derived water samples.

BACKGROUND: Colonization with Mycobacterium chimaera and other non-tuberculous mycobacteria (NTM) has been reported for heater-cooler devices (HCDs) produced by several manufacturers. Up until now, exclusively LivaNova (London, UK) HCDs have been associated with M. chimaera infections after cardiac surgery. The vast majority of studies on HCD colonization were cross-sectional. AIM: We were interested in longitudinal dynamics of mycobacterial growth in HCD water samples and analysed data of a prospective mycobacterial surveillance of five LivaNova 3T HCDs. METHODS: Five LivaNova HCDs were subjected to prospective mycobacterial surveillance. For each HCD and the total of HCDs, results of mycobacterial detection were analyzed. Logistic regression was applied to model the association between growth of any NTM or M. chimaera and duration of HCD use. RESULTS: Non-tuberculous mycobacteria were isolated in 319 (48.0%, 21 water samples grew more than one mycobacterial species) of a total of 665 water samples. The most frequently detected species were M. chimaera (N = 247/319, 77.4%), Mycobacterium gordonae (46/319, 14.4%) and Mycobacterium paragordonae (34/319, 10.7%). Detection rates increased prospectively for any NTM (odds ratio (OR) per year in use: 1.60, 95% confidence interval (CI) 1.17-2.24, P<0.001) and for M. chimaera (OR per year in use: 1.67, 95% CI 1.11-2.57, P<0.01). CONCLUSION: Longer duration of HCD use was associated with higher detection rates for any NTM and M. chimaera, respectively.

Thulium laser enucleation of the prostate (ThuLEP): transurethral anatomical prostatectomy with laser support. Introduction of a novel technique for the treatment of benign prostatic obstruction.

BACKGROUND: Transurethral removal of prostatic tissue is the treatment choice for benign prostatic enlargement and benign prostatic obstruction. Urodynamic results are directly linked to the amount of removed tissue which, however, is directly associated with intra- and postoperative morbidity. Transurethral laser operations of the prostate offer the advantage of decreased bleeding complications and the possibility to treat patients with bleeding disorders or anticoagulative treatment. The aim of the article is to present a novel technique of complete transurethral removal of the transition zone (enucleation) with the support of the Thulium laser to combine complete anatomical enucleation and maximum urodynamic efficacy with minimal side-effects. MATERIALS AND METHODS: We present five distinct surgical steps for transurethral complete removal of the transition zone of the prostate (Thulium laser enucleation of the prostate, ThuLEP). Surgical steps are presented in chronological order with the help of intraoperative pictures. Laser energy of 70-90 W is only used for the incision at the verumontanum and bladder neck for removal of the middle lobe, whereas laser energy of 30 W was only used for coagulation of small vessel crossing the surgical capsule towards the transition zone and bladder neck for dissection of the lateral lobes. The lobes themselves are liberated by blunt dissection. CONCLUSIONS: ThuLEP offers complete removal of the transition zone no matter what prostatic size. The techniques combine maximum efficacy with minimal side-effects. Clinical results comparing ThuLEP with open prostatectomy or transurethral resection are awaited.

Diversity of nontuberculous mycobacteria in Heater-Cooler Devices - results from prospective surveillance.

OBJECTIVE: The international outbreak of cardiac surgery-associated Mycobacterium chimaera infections was traced back to infectious aerosols originating from contaminated water reservoirs of heater-cooler devices (HCD). In general, nontuberculous mycobacteria (NTM) frequently colonize water systems and can contaminate medical devices. Data on detection of NTM other than M. chimaera in samples gathered from HCDs are scarce. The present study summarizes prospective mycobacterial surveillance of five HCDs over more than four years. METHODS: A cohort of five, in 2014 factory-new acquired, LivaNova 3T (London, UK) HCDs were prospectively followed. Until mid-April 2014 HCDs were maintained according to the manufacturer's recommendations, subsequently according to an intensified in-house protocol including exhaust air evacuation. Mycobacterial surveillance cultures consisted of monthly water samples gathered from patient and cardioplegia circuits, as well as airflow samples. RESULTS: Out of 441 water samples, 170 (38.6%) revealed NTM growth. The most frequently detected NTM were Mycobacterium chimaera (n=120 (67.4%)), Mycobacterium gordonae (n=35 (19.7 %)), and Mycobacterium paragordonae (n=17 (9.6%)). Growth of NTM, M. chimaera and M. paragordonae was significantly more common in water samples derived from the patient than the cardioplegia circuit of the HCD. Three (2.0%) out of 150 air samples grew NTM. CONCLUSION: Growth of NTM in HCD water samples was frequent. Diverse NTM species were detected, with M. chimaera being most common. The majority of air samples remained negative. The relevance of NTM other than M. chimaera contaminating HCDs is poorly defined, but a recent report on a HCD-associated outbreak with Mycobacterium abscessus confirms a potential threat.

Evaluation of Lightmix Mycoplasma macrolide assay for detection of macrolide-resistant Mycoplasma pneumoniae in pneumonia patients.

OBJECTIVES: Rapid detection of macrolide resistance-associated mutations in Mycoplasma pneumoniae is crucial for effective antimicrobial treatment. We evaluated the Lightmix Mycoplasma macrolide assay for the detection of point mutations at nucleotide positions 2063 and 2064 in the 23S ribosomal RNA (rRNA) gene of M. pneumoniae that confer macrolide resistance. METHODS: Samples from 3438 patients with a respiratory tract infection were analysed by M. pneumoniae real-time PCR, and 208 (6%) of them were tested positive. In this retrospective study, 163 M. pneumoniae real-time PCR-positive samples were analysed by the Lightmix assay, and results were compared to targeted 23S rRNA sequencing. RESULTS: Macrolide-resistant M. pneumoniae were found in 15 (9%) of 163 retrospectively analysed samples. The Lightmix assay showed a sensitivity of 100% (95% confidence interval, 78.2-100) and a specificity of 100% (95% confidence interval, 97.5-100) as the detected M. pneumoniae genotype (148 wild type and 15 non-wild type) was confirmed by 23S rRNA sequencing in all samples. CONCLUSIONS: The Lightmix assay is an easy-to-use and accurate molecular test that allows rapid determination of macrolide resistance in M. pneumoniae.

Toward a Flexible Variable Stiffness Endoport for Single-Site Partial Nephrectomy.

Laparoscopic partial nephrectomy for localized renal tumors is an upcoming standard minimally invasive surgical procedure. However, a single-site laparoscopic approach would be even more preferable in terms of invasiveness. While the manual approach offers rigid curved tools, robotic single-site systems provide high degrees of freedom manipulators. However, they either provide only a straight deployment port, lack of instrument integration, or cannot be reconfigured. Therefore, the current main shortcomings of single-site surgery approaches include limited tool dexterity, visualization, and intuitive use by the surgeons. For partial nephrectomy in particular, the accessibility of the tumors remains limited and requires invasive kidney mobilization (separation of the kidney from the surrounding tissue), resulting in patient stress and prolonged surgery. We address these limitations by introducing a flexible, robotic, variable stiffness port with several working channels, which consists of a two-segment tendon-driven continuum robot with integrated granular and layer jamming for stabilizing the pose and shape. We investigate biocompatible granules for granular jamming and demonstrate the stiffening capabilities in terms of pose and shape accuracy with experimental evaluations. Additionally, we conduct in vitro experiments on a phantom and prove that the visualization of tumors at various sites is increased up to 38% in comparison to straight endoscopes.

[Self-concept and erectile dysfunction in 45-year-old men : Results of a corollary study of the PROBASE trial]. / Selbstbild und erektile Dysfunktion 45-jähriger Männer : Ergebnisse eines Begleitprojekts der PROBASE-Studie.

BACKGROUND: Self-concept consists of self-perceptions and is influenced by the life course of the person. OBJECTIVES: This study investigated associations between self-concept and erectile dysfunction (ED) in 45-year-old German men. MATERIALS AND METHODS: Forty-five-year-old, heterosexual men who had participated in the PROBASE-study were included. Erectile Function was evaluated using the International Index of Erectile Function (IIEF-6). The presence of ED was defined by IIEF-6 score ≤ 25. Self-concept was assessed using the facets "body image" (three items from the Dresden Body Image Inventory, DKB-35), "perception of masculinity" (three items from the Male Role Norms Scale, MRNS), "perceived social pressure with regard to sexual performance" (four newly constructed items), and "sexual self-esteem" (three newly constructed items). Scores for these facets of self-concept can range from 1 to 5. Higher scores indicate a more positive body image, higher sexual self-esteem, a more modern understanding of masculinity, and greater perceived social pressure. Differences in self-concept between men with ED and without ED were analyzed using the Mann-Whitney-U-test. Furthermore, Cohen's d effect sizes (ES d) were calculated. RESULTS: The responses of 3143 men were analyzed. Men with ED (16.2 %) have significantly lower scores regarding body image (mean 3.6 ± 0.6 vs 3.8 ± 0.5; p < 0.001; ES d = -0.5), perception of masculinity (mean 3.4 ± 0.7 vs 3.7 ± 0.6; p < 0.001; ES d = -0.4), and sexual self-esteem (mean 3.6 ± 0.6 vs 3.9 ± 0.5; p < 0.001, ES d = -0.4) than men without ED. Furthermore, they had significantly higher scores for perceived social pressure (mean 2.1 ± 0.7 vs 1.5 ± 0.5; p < 0.001; ES d = 1.2). CONCLUSIONS: Self-concept and ED are associated in 45-year-old men. Men with ED have a more negative body image, a more traditional understanding of masculinity, more negative sexual self-esteem, and greater perceived social pressure with regard to sexual performance than men without ED.

[Partial Nephrectomy in cT1 Renal Tumours: Conventional Laparoscopic Partial Nephrectomy Compared with LESS Partial Nephrectomy in SITUS Technique]. / Nierenteilresektion bei cT1 Nierentumoren: Vergleich der konventionellen laparoskopischen Nierenteilresektion mit der LESS Nierenteilresektion in SITUS-Technik.

BACKGROUND: Partial nephrectomy is the treatment of choice for clinical stage 1 renal tumours. Open partial nephrectomy is the standard operative technique. The use of minimally-invasive strategies such as laparoscopic, robot-assisted partial nephrectomy or laparoendoscopic single site (LESS) partial nephrectomy has increased in recent years. PATIENTS/MATERIAL AND METHODS: In this retrospective study, patients undergoing laparoscopic partial nephrectomy between December 2008 and November 2013 were evaluated. All patients presented with renal lesions suspicious for malignancy. Operations were performed as conventional laparoscopic transperitoneal partial nephrectomies (cLPN) or LESS partial nephrectomies (LESS-PN) in SITUS technique (single incision transumbilical surgery). The aim of the study was to compare perioperative outcome parameters such as duration of surgery, time of ischaemia, complications, need for transfusion, conversion rates, changes in renal function and duration of hospital stay in both groups. RESULTS: A total of 85 laparoscopic partial nephrectomies were performed in this study (72 cLPN and 13 LESS-PN). The average tumour size was 2.68±1.47 cm (cLPN) vs. 2.46±1.11 cm (LESS-PN). The mean duration of surgery was 175.17±50.026 min (cLPN) and 185.77±35.991 min (LESS-PN). 45 (62.5%) operations (cLPN) vs. 10 (76.9%) (LESS-PN) were performed in zero-ischaemia technique. There were no significant differences in perioperative outcome parameters between both groups. Postoperative complication rates (Clavien-Dindo≥3) were 11.1% (cLPN) vs. 7.7% (LESS-PN). CONCLUSIONS: LESS partial nephrectomy in SITUS technique is an attractive alternative to conventional laparoscopic and open partial nephrectomy.

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

FlexGuard: a new laser insertion sheath: functional aspects in ureterorenoscopy (URS).

The evolution of flexible ureteroscopes led to a widespread use for the management of upper urinary tract abnormalities. The cost of purchase, maintenance and the durability of these instruments has become a major issue. This work describes a new device to avoid damages due to incorrect use of the Holmium laser during insertion of the laser fibre. A laser fibre with an optical core of 271 and 430 muicrom outside diameter was slid inside the FlexGuard laser fibre insertion sheath (LISA laser products, Germany). The outside diameter of the sheath measures 2.7 F (0.9 mm) and 2.1 F (0.7 mm) luminal diameter. The distal fibre tip was brought up to a position app. 2 mm inside the distal end of the sheath. The loaded sheath was pushed through the working channel of various ureteroscopes which were in maximum deflection. With the insertion sheath protruding about 2 mm from the distal tip of the URS the fibre was effortless forwarded out of the sheath to approach the stone. Once the laser fibre was in position, the sheath was removed, to increase the volume of irrigation fluid during laser lithotripsy. The radius of curvature (ROC) of the URS in maximum deflection and the integrity of the working channel was investigated. Using the insertion sheath the laser fibre reached the working position without any recognition of scratching or resistance. The integrity of the ureterorenoscopes was checked thoroughly be manually operated manometry. No damage of the inner surface of the working channel occurred. The ROC of the instrument did not change significantly during this procedure. After removal of the sheath the ROC remained stable. With the extended use of ureteroscopy, durability and repair costs are of concern. Damage resulting from incorrect use of laser fibres is a major issue in this respect. FlexGuard proved to avoid this damage in all flexible ureteroscopes investigated without limiting their mobility.

Effects of clofazimine alone or combined with dapsone on neutrophil and lymphocyte functions in normal individuals and patients with lepromatous leprosy.

The effects of clofazimine on neutrophil activities such as random motility, migration to the leukoattractants endotoxin-activated serum and N-formyl-L-methionyl-L-leucyl-L-phenylalanine phagocytosis of Candida albicans, postphagocytic hexose-monophosphate shunt activity, and myeloperoxidase-mediated iodination and the effects of clofazimine on lymphocyte transformation to mitogens were assessed in vitro and after ingestion of the drug by normal individuals and patients with lepromatous leprosy. For in vitro studies, the concentration range of the drug investigated was 10(-6) M to 10(-2) M. for in vivo studies, subjects ingested 200 mg of clofazimine daily for a period of 5 days. At concentrations of 5 X 10(-6) M to 5 X 10(-3) M clofazimine caused a progressive dose-dependent inhibition of neutrophil motility without detectable effects on phagocytosis, postphagocytic hexose-monophosphate shunt activity, or myeloperoxidase-mediated iodination. Over the same concentration range, clofazimine inhibited lymphocyte transformation. The inhibitory effect on neutrophil motility was associated with a spontaneous stimulation of oxidative metabolism and could be prevented by coincubation of dapsone with clofazimine. after ingestion of clofazimine responsiveness of lymphocytes to mitogens was decreased in normal volunteers and leprosy patients: neutrophil motility in normal individuals was likewise inhibited.