Simultaneous robotic assisted laparoscopic prostatectomy (RALP) and inguinal herniorrhaphy (IHR): proof-of-concept analysis from a high-volume center.

PURPOSE: Inguinal hernia (IH) is detected in approximately 33% of RALP's either pre or intraoperatively wherein all are repaired during RALP to circumvent future herniorrhaphy (Fukuta et al., Urology 68(2):267-271, 2006; Nielsen, Urology 66(5):1034-1037, 2005). Some debate this policy by quoting the potential risk of mesh lying close to the vesicourethral anastomosis leading to infections and adhesions. The current study was initiated to elucidate the feasibility and outcomes of simultaneous inguinal herniorrhaphy (IHR) during RALP. METHODS: Historic analysis of prospectively maintained data of 1224 RALP patients, as per inclusion criteria, between 2012 and 2017 was done, among whom 143 patients had a concurrent IHR using 3DmaxTM polypropylene monofilament mesh. Patients were then compared for demographics, peri-operative features, and outcomes. RESULTS: The mean age and AUA score were significantly different (p < 0.002, p < 0.01 respectively) between patients undergoing only RALP and RALP with IHR. BMI was not significantly different. One hundred forty-three patients (11.6%) underwent IHR at 155 hernial sites, 12 sites being bilateral. One hundred and one sites (65.2%) were diagnosed intraoperatively. The mean console time was 67.4 ± 11.5 min for RALP which increased by 6.9 ± 10.7 min in unilateral and by 10.7 ± 8.6 min in bilateral IHR. There were no mesh-associated or Clavien Dindo class II-V complications. Mean follow-up was 36 ± 1.4 months with no recurrences. CONCLUSION: This study reiterates the feasibility and advisability of repairing most inguinal hernias encountered during RALP as it is without any significant alteration of peri-operative morbidity, is associated with excellent post-operative outcomes, and obviates the need for a future surgical procedure.

Sexual dimorphism in BDNF signaling after neonatal hypoxia-ischemia and treatment with necrostatin-1.

Brain injury due to neonatal hypoxia-ischemia (HI) is more homogenously severe in male than in female mice. Because, necrostatin-1 (nec-1) prevents injury progression only in male mice, we hypothesized that changes in brain-derived neurotrophic factor (BDNF) signaling after HI and nec-1 are also sex-specific providing differential conditions to promote recovery of those more severely injured. The increased aromatization of testosterone in male mice during early development and the link between 17-ß-estradiol (E2) levels and BDNF transcription substantiate this hypothesis. Hence, we aimed to investigate if sexual differences in BDNF signaling existed in forebrain and diencephalon after HI and HI/nec-1 and their correlation with estrogen receptors (ER). C57B6 mice (p7) received nec-1 (0.1µl [8µM]) or vehicle (veh) intracerebroventricularly after HI. At 24h after HI, BDNF levels increased in both sexes in forebrain without evidence of tropomyosin-receptor-kinase B (TrkB) activation. At 96h after HI, BDNF levels in forebrain decreased below those seen in control mice of both sexes. Additionally, only in female mice, truncated TrkB (Tc.TrkB) and p75 neurotrophic receptor (p75ntr) levels increased in forebrain and diencephalon. In both, forebrain and diencephalon, nec-1 treatment increased BDNF levels and TrkB activation in male mice while, nec-1 prevented Tc.TrkB and p75ntr increases in female mice. While E2 levels were unchanged by HI or HI/nec-1 in either sex or treatment, ERα:ERß ratios were increased in diencephalon of nec-1-treated male mice and directly correlated with BDNF levels. Neonatal HI produces sex-specific signaling changes in the BDNF system, that are differentially modulated by nec-1. The regional differences in BDNF levels may be a consequence of injury severity after HI, but sexual differences in response to nec-1 after HI may represent a differential thalamo-cortical preservation or alternatively off-target regional effect of nec-1. The biological significance of ERα predominance and its correlation with BDNF levels is still unclear.

Minimizing minimally invasive surgery: the 5-mm trocar laparoscopic pyeloplasty.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty has evolved into the procedure of choice when definitive repair of the obstructed ureteropelvic junction is contemplated. Its main advantage over the gold standard of open pyeloplasty is decreased morbidity. We have utilized only three 5-mm ports in our last 15 pyeloplasties in an effort to further reduce morbidity and improve acceptance by an often-younger patient population. PATIENTS AND METHODS: Fifteen consecutive patients underwent laparoscopic transperitoneal pyeloplasty by the 5-mm port technique. Three trocars were utilized, two for the working instruments and one for a 5-mm telescope mounted on a voice-activated robotic arm (AESOP; Intuitive Surgical, Sunnyvale, CA). Three patients required an additional trocar for liver retraction. All patients underwent dismembered pyeloplasty and had indwelling double-pigtail stents placed for 4 to 6 weeks. RESULTS: The mean operative time was 195 minutes (range 120-240 minutes). The average blood loss was 30 mL. None of our patients required open conversion. With a median follow-up of 10 months (range 3-15 months), all 15 patients have shown both subjective (freedom from symptoms) and objective (renal scan) improvement. CONCLUSION: We believe our technique has further minimized the morbidity of laparoscopic pyeloplasty without compromising the outcome. The 5-mm trocars obviate fascial closure, decrease patient discomfort, and improve cosmesis. Furthermore, the use of the robotic arm eliminates the need for a surgical assistant and makes this an essentially "one-person" procedure.

Surgeon's workshop: a simple method of antegrade collagen placement for postprostatectomy incontinence.

We describe a modified method for antegrade placement of periurethral collagen in incontinent men. In this technique, a flexible cystoscope is used to guide the placement of a specially designed needle into the bladder neck and external sphincter region via an antegrade transvesical approach. The 19-gauge, 28-cm long needle is passed suprapubically without a sheath. The procedure may be performed with local anesthesia and intravenous sedation only and takes less than 30 minutes.

Schistosomal myelopathy as a cause of neurogenic bladder dysfunction.

Schistosoma hematobium most commonly affects the bladder and S. mansoni has a predilection for the liver, spleen, and the mesenteric territories. Schistosomal spinal cord involvement is an extremely unusual primary presentation of schistosomiasis, especially in the United States. We report 2 patients with documented schistosomiasis who presented with urinary incontinence as their chief urologic complaint. One patient had no sensorimotor deficit and presented with isolated incontinence as the harbinger of spinal involvement. The other patient presented 5 years after initial exposure, emphasizing the possibility of a long latent period between exposure and onset of symptoms.

Prevalence and pattern of major neurological disorders in rural Kashmir (India) in 1986.

In 1986 in the Kuthar Valley in the Anantnag District of south Kashmir (northwestern India), we studied the population to ascertain the prevalence and pattern of various neurological diseases. A house-to-house survey was done in a rural population of 63,645 (according to a World Health Organization protocol, 1981). 616 cases of major neurological disorders were detected, yielding a prevalence of ratio of 9.67/1,000 as of prevalence day November 1, 1986. The prevalence ratios for various common neurological disorders were: epilepsy 2.47/1,000; stroke 1.43/1,000; paralytic poliomyelitis 2.18/1,000; mental retardation 2.09/1,000; deaf mutism 1.63/1,000, and cerebral palsy 1.24/1,000. Persons with these conditions constituted 92% of all neurological cases. Patients with motor neuron disease, Alzheimer's dementia or multiple sclerosis were not found.

Epidemiology of young strokes in rural Kashmir, India.

Kuthar valley in the Anantnag district of south Kashmir (North-west India) was surveyed to ascertain the prevalence of completed strokes. In a population of 63,645, the survey was from July to November 1986; 91 cases of completed stroke were detected giving a crude prevalence of 143/100,000. Only 10 (10.9%) cases (7W: 3M) were in the age group 15-39 years, a prevalence rate of 41/100,000.

Cerebrovascular disease in rural Kashmir, India.

We studied the Kuthar Valley in the Anantnag District of south Kashmir (northwestern India) during the year 1986 to ascertain the prevalence and pattern of completed stroke. We detected 91 cases, giving a crude prevalence rate of 143/100,000. However, age-specific prevalence was 41/100,000 in the group aged 15-39 years and 630/100,000 in the group aged greater than or equal to 40 years; 69.23% of the cases were in men. Hypertension was present in 58.24% of the cases, while strokes due to valvular heart disease and puerperium-related strokes were most common in the young. Our study is first of its kind in this part of India.

Eating epilepsy.

Fifty cases of eating epilepsy (EE) are reported. Mastication of food produced seizures in 49 (98%) and swallowing in 1 (2%). Complex partial seizure was found in 48 cases, the commonest form encountered (96%). EEG was abnormal in 15 cases (30%). The literature and possible mechanisms for seizure are discussed.

Prevalence and pattern of epilepsy (Lath/Mirgi/Laran) in rural Kashmir, India.

The rural population of 63,645 living in the mountainous Kuthar Valley of South Kashmir, Northwest India was surveyed to determine the prevalence of major neurologic disorders, including epilepsy (called Lath/Mirgi/Laran in the local language). The survey was done according to a World Health Organization protocol (1981). House-to-house screening was done by Anganwadi workers to identify people with possible epilepsy. The screening questionnaire was translated into local vernacular. Persons who had some indication of a history of seizures or other neurologic disease were subsequently examined by a neurologic team. The diagnostic criteria of Hauser and Kurland (1975) were used to define cases of active epilepsy and seizure classification (ILAE, 1981) was done only with clinical data. One hundred fifty-seven cases of active epilepsy were detected, giving a crude prevalence rate of 2.47/1,000 general population. In those aged less than 14 years, prevalence was 3.18/1,000. Ninety-five (60.5%) of all cases were male; 91% of active epilepsy cases had onset of seizures before age 30 years. Mean age of onset in males was 5.3 years, and in females it was 7.1 years. Mean duration of seizures was 6 years; 78.9% cases had generalized seizures, 74.5% cases were receiving no specific treatment, 99.4% cases were born of home delivery, and 8.9% cases had a positive family history of seizures. Mental retardation was the most common associated abnormality in 22.9% of cases.