Impact of intraoperative fluid administration on outcome in patients undergoing robotic-assisted laparoscopic prostatectomy--a retrospective analysis.

BACKGROUND: Robotic-assisted laparoscopic prostatectomy (RALP) gained much popularity during the last decade. Although the influence of intraoperative fluid management on patients' outcome has been largely discussed in general, its impact on perioperative complications and length of hospitalization in patients undergoing RALP has not been examined so far. We hypothesized that a more restrictive fluid management might lead to a shortened length of hospitalization and a decreased rate of complications in our patients. METHODS: Retrospective analysis of data of 182 patients undergoing RALP at an University Hospital (first series of RALP performed at the center). RESULTS: The amount of fluid administered was initially normalized for body mass index of the patient and the duration of the operation and additionally corrected for age and the interaction of these variables. The application of crystalloids (multiple linear regression model, estimate = -0.044, p = 0.734) had no effect on the length of hospitalization, whereas a negative effect was found for colloids (estimate = -8.317, p = 0.021). Additionally, a significant interaction term between age and the amount of colloid applied (estimate = 0.129, p = 0.028) was calculated. Evaluation of the influence of intraoperative fluid administration using multiple logistic regression models corrected for body mass index, duration of the surgery and additionally for age revealed a negative effect of crystalloids on the incidence of an anastomotic leak between bladder and urethra (estimate = -23.860, p = 0.017), with a significant interaction term between age and the amount of crystalloids (estimate = 0.396, p = 0.0134). Colloids had no significant effect on this particular complication (estimate = 1.887, p = 0.524). Intraoperative blood loss did not alter the incidence of an anastomotic leak (estimate = 0.001, p = 0.086), nor did it affect the length of hospitalization (estimate = 0.0001, p = 0.351). CONCLUSIONS: In accordance to the findings of our study, we suggest that a standardized, more restrictive fluid management might be beneficial in patients undergoing RALP. In older patients this measure would be able to shorten the length of hospitalization and to decrease the incidence of anastomosis leakage as a major complication.

The University Hospital Zurich Offers a Medical Online Consultation Service for Men With Intimate Health Problems.

The University Hospital of Zurich offers a text-based, Medical Online Consultation Service to the public since 1999. Users asked health questions anonymously to tele-doctors. This study focused on the characteristics of male enquirers with intimate health problems, the content of their questions, the medical advice given by tele-doctors and the rating of the service to prove the benefit of an online service for medical laymen. This retrospective study included 5.1% of 3,305 enquiries from 2008 to 2010 using the International Classification of Diseases-10 and International Classification of Primary Care codes relevant for intimate and sexual health problems in men. A professional text analysis program (MAXQDA) supported the content analysis, which is based on the procedure of inductive category development described by Mayring. The average age was 40 years, 63.1% enquirers had no comorbidity, in 62.5% it was the first time they consulted a doctor, and 70.2% asked for a specific, single, intimate health issue. In 64.3%, the most important organ of concern was the penis. Overall, 30.4% asked about sexually transmitted diseases. In 74.4% a doctor visit was recommended to clarify the health issue. The rating of the problem solving was very good. The service was mainly used by younger men without comorbidity and no previous contact with a doctor with regard to an intimate health problem. The anonymous setting of the teleconsultation provided men individual, professional medical advice and decision support. Teleconsultation is suggested to empower patients by developing more health literacy.

Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer: surgical technique and experience with the first 99 cases.

BACKGROUND: To date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. OBJECTIVE: To assess the technical feasibility of RALEPLND and to present our surgical technique. DESIGN, SETTING, AND PARTICIPANTS: From April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. Indications for RALEPLND were a prostate-specific antigen (PSA) > or = 10 ng/ml or a preoperative Gleason score > or = 7. The data were evaluated retrospectively. SURGICAL PROCEDURE: The transperitoneal approach was used in all cases. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides. MEASUREMENTS: The total lymph node yield, the frequency of lymph node metastases, and the complication rate. RESULTS AND LIMITATIONS: The median patient age was 64 yr (range: 45-78). The median preoperative PSA level was 7.7 ng/ml (range: 1.5-84.6). The median number of lymph nodes harvested was 19 (range: 8-53). In 16 patients (16%), we found lymph node metastasis. Complications occurred in seven patients (7%). CONCLUSIONS: RALEPLND is feasible, and its lymph node yield is well in the range of open series. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon's ability to perform a complete extended pelvic lymph node dissection.

Botulinum toxin-A for idiopathic overactivity of the vesical detrusor: a 2-year follow-up.

The aim of this trial was to examine the effects after 2 years of a single intravesical botulinum toxin-A injection (BTX-A). This prospective, observational study was conducted using urodynamic measurements and quality of life (QoL) assessment to document the effect after 2 years of a single 100 I.U. injection of BTX-A into the vesical detrusor muscle. Twenty-six patients were followed up for 2 years after a first intravesical BTX-A injection. Of these 26 patients, one was a primary failure, three were lost to follow-up, and 11 patients had a repeated injection at 5-26 months (one patient had a third injection). Seven of the remaining 11 patients in the single injection group were recommended repeated injection or another treatment, and four required no other treatment. In conclusion, 2 years after a single BTX-A injection statistically significant differences in urodynamics and an improvement in QoL could still be demonstrated.

Efficacy of botulinum-A toxin in the treatment of detrusor overactivity incontinence: a prospective nonrandomized study.

OBJECTIVE: This study was undertaken to investigate the efficacy and safety of botulinum-A toxin (BTX-A) treatment for non-neurogenic detrusor overactivity incontinence. STUDY DESIGN: This prospective nonrandomized ongoing study was performed in a tertiary referral urogynecology department. In 26 women with urge incontinence and urodynamically demonstrated detrusor overactivity incontinence resistant to conventional treatment 100 units of BTX-A were injected into the detrusor muscle at 30 sites. Clinical and urodynamic evaluations and a quality of life assessment were performed at baseline and 4, 12, and 36 weeks after BTX-A treatment. RESULTS: Of 26 women, 14 were dry after 4 weeks, 13 of 20 women after 12 weeks, and 3 of 5 women after 36 weeks. Two women failed to respond. Two women were on self-catheterization temporarily. There were no other complications besides 9 urinary tract infections within the 51 follow-up visits. CONCLUSION: BTX-A treatment seems to be a safe and efficacious new treatment option for patients with detrusor overactivity incontinence.

Urethral evoked sympathetic skin responses and viscerosensory evoked potentials as diagnostic tools to evaluate urogenital autonomic afferent innervation in spinal cord injured patients.

PURPOSE: In most spinal cord injured (SCI) patients the objective assessment of afferent neuronal pathways from the lower urinary tract and the recording of a disturbed urethral sensation and/or desire to void are still difficult. Viscerosensory evoked potentials (VSEPs) might be helpful, but they remain technically difficult to obtain and interpretation is delicate. As a new approach, sympathetic skin response (SSR) of the hand and foot were recorded after electrical stimulation of the posterior urethral mucosa. This technique should allow assessment of the integrity or deterioration of the autonomic afferent pathway. MATERIALS AND METHODS: A total of 20 males and 8 females with SCI somatosensory incomplete 15, somatosensory complete 13 and 6 healthy male volunteers were prospectively examined. During urodynamic examination electrical stimulation (single square pulses of 0.2 ms, 2 to 3-fold sensory threshold, 60 mA in complete SCI patients) of the posterior urethra/bladder neck was performed using a bipolar electrode inserted into a microtip pressure catheter. SSR recordings of the right palm and sole were simultaneously taken using surface electrodes and were analyzed by an electromyography unit. Patient reports on evoked urethral sensations at individual sensory thresholds were simultaneously noted. Additionally, well-known electrophysiological measurements such as pudendal sensory evoked potential and urethral VSEP were recorded to check clinical assessed somatosensory and viscerosensory status, and to compare SSR results with these conventional methods. RESULTS: Electrical stimulation of the posterior urethra evoked clear urethral sensation and SSRs in normal subjects. In 14 of 15 sensory incomplete SCI patients with disturbed urethral sensation SSRs could be recorded as well. Electrically evoked urethral sensations resembled the subjective desire to void at full bladder reported by controls and patients. In 13 sensory complete SCI patients with loss of any urethral sensation SSRs could not be recorded even at maximal electrical stimulation strength. All subjects with electrically induced urethral sensation had positive evoked (supralesional) SSRs of the hand. However, none of the patients with absent urethral sensation presented SSRs. Simultaneously recorded VSEPs could not be recorded clearly in 5 patients and 2 control subjects, whereas SSRs delivered clear results in all controls and patients, matching their reports. CONCLUSIONS: SSR recordings above a spinal lesion level after urethral electrostimulation might provide a useful and technically simple objective diagnostic tool to assess integrity of autonomic (visceral) afferent nerves from the lower urinary tract. Somatosensory deficits are not always paralleled by viscerosensory loss and vice versa. In this study SSRs were superior to VSEPs, the latter being more difficult to record. The subjective sensations reported by subjects during stimulation could be confirmed in an objective way in 100% of cases by positive/negative SSR findings.

A new high frequency electrostimulation device to treat chronic prostatitis.

PURPOSE: We prospectively observed a possible benefit from urethro-anal high frequency electrostimulation in patients with noninflammatory chronic pelvic pain syndrome (Cat IIIB CPPS) as a new treatment option. MATERIALS AND METHODS: A total of 88 patients with a referral diagnosis of chronic prostatitis underwent fractionated urinary cultures, including expressed prostate secretion and ejaculate analysis twice. Of this group 14 men with Cat IIIB CPPS elected electrostimulation. A urethro-anal stimulation device was applied twice weekly for 30 minutes during 5 weeks at a defined voltage of 6 V, a defined frequency of between 450 and 500 Hz, and a variable self-regulated current of between 1 and 10 mA. National Institutes of Health prostatitis symptom score and quality of life index were determined before and after the treatment. RESULTS: All patients tolerated stimulation and completed the treatment course. No urethral or anal complications occurred. Generally, the patients reported a distinct perineal feeling and the pain syndrome improved in 83%. The mean total National Institutes of Health prostatitis symptom score significantly decreased from 29 (range 20 to 37) to 14 (range 8 to 24) points (p = 0.002). Mean pain decreased from 15 (range 12 to 20) to 7 (range 4 to 13) points (p = 0.002). Micturition complaints decreased from 2.5 (range 0 to 9) to 1 (range 0 to 8) points (p = 0.007) and quality of life improved from 9.5 (range 8 to 12) to 5.5 (range 3 to 10) (p = 0.003). CONCLUSIONS: To date the new high frequency urethro-anal afferent electrostimulation device seems to have an important benefit in patients with Cat IIIB CPPS. The device is technically simple and it can be self-administered. Therefore, it may become a new ambulatory treatment option for patients with chronic pelvic pain syndrome.