Robot-assisted laparoscopic radical hysterectomy: comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; one surgeon's experience at the Norwegian Radium Hospital.

OBJECTIVES: The purpose of this study was to investigate the 3 years follow-up results regarding the recurrence pattern of robot-assisted laparoscopic radical hysterectomies and pelvic lymphadenectomies in the early stage cervical carcinoma patients and compare the results with both total laparoscopic radical hysterectomy and abdominal radical hysterectomy groups. METHODS: A total of 68 patients underwent radical hysterectomy and pelvic lymphadenectomy for early stage cervical carcinoma management. All cases (35 robot-assisted, 7 cases laparoscopy and 26 with laparotomy) were operated by the same surgeon at the Norwegian Radium Hospital. All cases were retrospectively reviewed to compare demographics, peri-operative variables such as mean operative time, estimated blood loss, lymph node counts, complications and follow-up results. RESULTS: The mean operating times (skin-to-skin) for patients undergoing robot-assisted laparoscopic radical hysterectomy (RALRH), total laparoscopic radical hysterectomy (TLRH) or abdominal radical hysterectomy (ARH) were 263±70, 364±57 and 163±26 min respectively. Patients receiving laparotomy had shortest operative time, followed by those undergoing RALRH and then laparoscopy (p<0.0001 for both). Estimated blood loss was significantly reduced in robot-assisted surgeries compared to surgeries involving laparoscopy and laparotomy (82±74 ml vs. 164±131 ml (p<0.0001) and 595±284 ml (p=0.023), respectively). The mean follow-up times were 36±14.4, 56.4±14 and 70±21 months in patients who underwent RALRH, TLRH and ARH respectively. Until now there have been 5 recurrences and one cervical cancer related death in the robot-assisted group and no recurrences in both the laparoscopy and the laparotomy group. One patient died due to primary lung cancer in the laparoscopic group and other patient died due to primary pancreatic cancer in the laparotomy group. CONCLUSIONS: Robot-assisted laparoscopic radical hysterectomy and pelvic lymph node dissection is feasible and more precise because the instruments provide better flexibility and 3-D vision. We must proceed cautiously, however, if a new treatment modality appears to present an increased recurrence rate. Therefore, patients submitted to robot-assisted laparoscopic radical hysterectomy should be followed carefully and RALRH would be encouraged as protocol setting until the long-term oncological outcome data are available.

Piperacillin/tazobactam versus imipenem/cilastatin for severe diabetic foot infections: a prospective, randomized clinical trial in a university hospital.

In this prospective, randomized, open-label clinical trial, we compared the efficacy and safety of two antibiotic regimens for severe diabetic foot infections (DFI). Sixty-two in-patients with DFI received either piperacillin/tazobactam (Pip-Tazo, n = 30) (4.5 g intravenously every 8h) or imipenem/cilastatin (IMP, n = 32) (0.5 g intravenously every 6h). The mean duration of treatment was 21 days for Pip-Tazo and 24 days for IMP. Twenty-two (73.3%) patients in the Pip-Tazo group and 26 (81.2%) patients in the IMP group had DFI associated with osteomyelitis. Successful clinical response was seen in 14 (46.7%) patients in the Pip-Tazo group and in nine (28.1%) patients in the IMP group [relative risk (RR) 1.6 (95% CI 0.84-3.25), p 0.130]. Two patients in the IMP group and none in the PIP-Tazo group relapsed [RR 2 (0.94-4.24), p 0.058]. Eighty-nine microorganisms were isolated: 38 (43%) Gram-positive and 51(57%) Gram-negative. Among patients with positive culture, 47 (96%) had complete and two (4%) had partial microbiological response. Microbiological response rates were similar in both groups (p 1.000). Amputation was performed in 18 (60%) and 22 (69%) patients in the Pip-Tazo and IMP groups (p 0.739) respectively. Side effects were more common in the Pip-Tazo group (30% vs. 9.4%), but they were generally mild and reversible. In conclusion, although the sample size was small and the results did not reach statistical significance, Pip-Tazo produced a better clinical response rate than IMP in the treatment of severe DFI. There was no significant difference between the treatment groups with respect to microbiological response, relapse and amputation rates.

Robot-assisted laparoscopic surgery in gynaecological oncology; initial experience at Oslo Radium Hospital and 16 months follow-up.

BACKGROUND: This study aimed to report our initial experience using the Da Vinci, a three-armed Intuitive Surgical robotic unit, in relation to gynae-oncological operations. METHODS: A prospective database was used in this retrospective analysis of 53 consecutive women with gynae-oncological diseases who were operated by the same surgeon in a single institution. All the patients were informed of the risks inherent with each surgical procedure as well as the potential advantages. RESULTS: 125 different procedures were performed, including total robotic radical hysterectomy (n = 25), restaging with total hysterectomy and bilateral salpingo-oophorectomy, total omentectomy, appendectomy, bilateral pelvic and para-aortic node dissections. Mean age of the patients, 45.8 (range 27-70) years; mean operative time, 219 (range 110-530) min; mean console time, 170 (range 60-445) min; mean estimated blood loss, 57 (range 10-300) ml; mean post-operative stay, 3 (range 1-6) days. No robot-related complications occurred. No conversions were reported. Mean follow-up time was 16 (range 0-28) months. CONCLUSIONS: Our preliminary experience with robotic surgery suggest that it is a safe technique and could allow complex radical operations to be performed with greater precision.

Is there any relationship between toxoplasma infection and reactive arthritis?

BACKGROUND: The diagnosis of reactive arthritis is a challenging clinical problem in daily practice. Although there are many triggering infectious agents for reactive arthritis, Toxoplasmosis, a worldwide parasitic infection has not been reported. AIM: We investigated the serologic evidence of Toxoplasma gondii ( T. gondii ) infection in patients with newly diagnosed reactive arthritis after six weeks of the onset of the first symptom but no demonstrable triggering agent for reactive arthritis. SETTING AND DESIGN: Clinical controlled study. MATERIALS AND METHODS: We screened serologically the serum toxoplasma IgM and IgG antibody (Ab) titers which revealed toxoplasma infection in 50 patients with reactive arthritis (40 female, 10 men) and no demonstrable triggering agent and control subjects (32 female, 8 male). STATISTICAL ANALYSIS: SPSS 10.0 software package program was used. RESULTS: The mean age of the patients and controls was similar (41.3+/- 12.0 vs. 39.6+/-11.8 years) respectively. The prevalence of IgG Ab titers of T. gondii in patients and controls were found to be 52% and 47.5%, respectively. Mean serum Toxoplasma IgG Ab levels were found to be 16.5+/-14.5 IU/ml, and 16.9+/-13.8 IU/ml in patients and control subjects respectively ( P> 0.05). We did not find any Toxoplasma IgM Ab titer demonstrating the acute or sub-acute infection in the serum of patients or controls. CONCLUSION: Although past Toxoplasma infection was prevalent in both groups, we did not find any subject with acute Toxoplasma infection in patients with newly diagnosed reactive arthritis and healthy controls. Despite the fact that our study group was small, we suggest that T. gondii does not seem to be a triggering agent for reactive arthritis and past infection may be a coincidental finding.

Effect of hyperthyroidism and propylthiouracil treatment on liver biochemical tests.

Liver biochemical test (LBT) changes can be commonly observed in hyperthyroid patients. Those kinds of changes could also be observed because of propylthiouracil (PTU) therapy. We prospectively evaluated LBT changes because of PTU use for 1 year in patients who had been diagnosed with hyperthyroidism first. We studied 64 patients who had been diagnosed with hyperthyroidism. These patients took at least 1-year PTU treatment. We analysed LBT at diagnosis and after 2 and 12 months of treatment with PTU. Prior to PTU treatment, 30 (46.8%) of the 64 patients had at least one LBT abnormality. We observed at least one LBT abnormality in 11 (32%) patients after 2 months and nine (26%) patients after 12 months of treatment with PTU in 34 patients whose CBT were normal before treatment. We did not observe any deterioration in clinical picture and bilirubin levels. Elevated serum LBT during the pretreatment and PTU treatment period is common and usually transient and asymptomatic. PTU could be used for long times by lowering the dose and close follow-up in patients who have elevated LBT during the pretreatment and after PTU treatment period.

Bladder pheochromocytoma encountered on sonography.

Pheochromocytomas of the bladder are rare neoplasms, constituting < 0.06% of all vesical tumours. Common presenting features of this tumour include episodes of sweating, hypertension, haematuria and postmicturition syncope. We describe a case of bladder pheochromocytoma in a 66-year-old man whose only symptom of macroscopic haematuria was initially assessed with ultrasonography. Clinical presentation highlights the need for a high index of suspicion during sonographic evaluation of bladder neoplasms because such tumours might present without symptoms of adrenergic excess.

Type 2 diabetes mellitus and osteopenia: is there an association?

We report the results of bone mineral density (BMD) measurements in type 2 diabetic patients, in comparison to healthy controls. In this prospective study, a total of 277 subjects (aged 30-60 years) with type 2 diabetes mellitus, outpatients at the Cukurova Medical School Hospital, were evaluated for BMD at L(1)-L(4) lumbar vertebrae and at the femur (neck, trochanter, Ward's triangle and total) by DEXA (dual energy X-ray absorptiometry). The patients' diabetes duration, treatment, glycemic control and chronic diabetic complications were recorded, and these data were evaluated for any relationship in respect to the BMD measurements. BMD results of the diabetic patients were compared with those of 262 healthy non-diabetic control subjects living in the same geographic region. BMD was found to be increased at the femoral neck among diabetic women and men aged 51-60 years. However, BMD values at lumbar regions of diabetic men where lower than control in all age group. There was no difference in values of BMD for both genders in the other regions. Type 2 diabetic patients may have lower, similar or higher BMD measurements at different ages and anatomic regions, so each patient should be evaluated individually. Further studies are needed to make a conclusion on this issue.

Use of the ultrasound surgical aspirator in ovarian cancer: a case-control study.

BACKGROUND: This study was undertaken to evaluate the use of the ultrasound surgical aspirator in ovarian cancer and to determine if cytoreduction was improved with its use. METHODS: The study is a retrospective case control trial. Twenty-six consecutive ovarian cancer patients who had the ultrasound surgical aspirator used during their surgery were retrospectively compared to 25 consecutive ovarian cancer patients who did not have the ultrasound surgical aspirator used during their surgeries. The latter group had their surgeries immediately before the ultrasound surgical aspirator was introduced into the hospital. Both groups were similar in age, stage, histology type, grade, and median number of chemotherapy cycles. RESULTS: Patients that had the ultrasound surgical aspirator used had a 69% optimal cytoreduction rate compared to 16% in the control group (p = .001). This was statistically significant (p = 0.001). Survival time was equal in both groups. CONCLUSIONS: Results of the study showed that use of the ultrasound surgical aspirator may permit more patients to be optimally cytoreduced.

Efficacy of indapamide in central diabetes insipidus.

BACKGROUND: Central diabetes insipidus (CDI) results from deficient vasopressin (antidiuretic hormone) secretion and causes polydipsia and polyuria. Desmopressin, a synthetic analog of vasopressin, is the drug of choice in the treatment of CDI, but in mild cases, there are alternative drugs that can be used, including chlorpropamide, carbamazepine, and thiazides. METHODS: In this study, we investigated the efficacy of treatment with indapamide, which is an antihypertensive diuretic oral agent, in 20 consecutive patients with CDI. The diagnosis of CDI was established by water-deprivation and vasopressin tests. Before the study, serum and urinary osmolality, daily urinary volume, and serum electrolyte levels were measured in all 20 patients. Indapamide (2.5 mg/d) was administered for 10 days, and then the investigations were performed again; for purposes of comparison, 250 mg/d of chlorpropamide was also administered to 11 of the 20 patients who had been given indapamide. RESULTS: Indapamide revealed a 40.56% +/- 9.70% (mean +/- SD) (range, 19.6%-55.0%) reduction in 24-hour urinary volume and an increase in urinary osmolality, as well as a decrease in serum osmolality, and was as effective as chlorpropamide (P<.05) in the treatment of CDI. CONCLUSION: Because of its low cost and lack of significant adverse effects, indapamide may be a suitable, easy-to-use alternative oral agent for some patients with CDI.

Malignant rhabdoid tumor of the vulva. Case report.

The poor prognosis of malignant rhabdoid tumor is emphasized and histopathological criteria for distinction from epithelial sarcoma of the vulva are discussed. Immunohistochemical analyses were performed by using nine different antigens including vimentin, cytokeratin, epithelial membrane antigen, carcinoembryonic antigen, desmin, muscle-specific actin, S-100 protein, AP-15, neuron specific enolase. This is the sixth reported case of a malignant rhabdoid tumor of the vulva. The patient died eight months after the initial diagnosis in spite of a combination of surgery, adjuvant chemotherapy and external radiotherapy.

Preliminary technique of laparoscopic extraperitoneal infrarenal paraaortic lymphadenectomy in the porcine model.

We developed an extraperitoneal approach to laparoscopic infrarenal paraaortic lymphadenectomy in the porcine model, with the ultimate aim of shortening the long learning curve of this procedure in humans. Surgery was performed on four females pigs with three 10-mm cannulas placed along the midaxillary line in prone position. The first and second pigs underwent subsequent laparotomy to evaluate the adequacy of lymph node dissection and complications. In all four animals, complete infrarenal paraaortic lymphadenectomy was successful, retrieving between 6 and 11 lymph nodes (average 9). Laparotomy in the first two animals confirmed adequate lymphadenectomy. No complications occurred. Operating time was shortened dramatically with each procedure (180, 120, 50, 40 min). In the porcine model this approach provides excellent exposure to the entire paraaortic lymphatic chain, is safe, and has a remarkably short learning curve. Development of a similar technique in humans may have significant advantages, including short learning curve, feasibility in obese patients and those with peritoneal adhesions, decreased adhesion formation, and reduced bowel complications associated with postoperative adjuvant irradiation. Further studies are indicated.

Cost, quality of life and outcome measures in ovarian cancer.

As research into cancer intensifies and treatments proliferate, life-interval gained is no longer a question of simply measuring time. Ovarian cancer patients, especially, have benefited from efforts to develop feasible screening processes and the new treatment modalities for this type of cancer. Within the last decade, medicine has come to realize that survival intervals and cure rates are useless to patients if they cannot retrieve out of the process at least some aspects of their lives before cancer and for as long a period of time as possible. This article focuses on measuring and assessing the effects of treatment in terms of outcome and quality of life from the patient's perspective. Medicine as a science, and being a science, has not been comfortable in taking into account intangibles when assessing its own performance and success rates. However, the roles of caregivers and health providers have been rapidly evolving from that of treating the disease to treating the patient, and often the patient's family, with all that implies.

Gynecologic oncology patients in the surgical ICU. Impact on outcome.

OBJECTIVE: To determine the risk factors and outcome for survival of gynecologic oncology patients in the surgical intensive care unit (SICU). STUDY DESIGN: A chart review from January 1987 through May 1992 yielded 73 gynecologic oncology patients with a malignancy who had undergone surgery with a minimum stay of three days in the SICU. Of these 73 patients, 49 patients died of malignancy, 5 were alive with disease, and 19 were alive without evidence of disease. RESULTS: The median survival of the 73 patients was 123 days; that of 48 ovarian cancer patients was 50 days. Twenty patients (27.4%) died in the hospital. CONCLUSION: This study, with multivariate analysis, showed that multiple medical conditions, especially cardiac disease, and a stay of longer than five days in the SICU had a significant impact on survival, with ovarian cancer patients staying longer and having poorer survival. These results will help in triaging patients for postsurgical management.

Prolonged stays of OB/GYN patients in the surgical intensive care unit. A cost-benefit analysis.

OBJECTIVE: To delineate costs between various obstetric and gynecologic (OB/GYN) patients with stays in the surgical intensive care unit (SICU). STUDY DESIGN: A chart review identified 86 OB/GYN patients who had a minimum SICU stay of three days between January 1987 and May 1992. RESULTS: Our study showed that the total cost of these cases was $3,344,010, with a median of $29,780 (range, $20,230-180,610) and that the difference between patients with malignancies and those without (median, $20,340) was not statistically significant (P = .11). However, cases of malignant disease that had either a prexisting medical condition or an SICU stay of more than five days cost more than any other cases (P = .038). The SICU share of total hospital cost ranged from 20.7% in patients with malignancy to 40% in patients without malignancy. CONCLUSION: As health care costs come under closer scrutiny, the critically ill patient should not be placed at risk of lessened chances of survival because perceived savings result in decreasing quality of care.

An unusual amebic localization on the right hip.

We report the history of a 43-year-old man with a histopathologically confirmed invasive amebic abscess in his right hip. CT scan of the liver was normal. The amebic indirect hemagglutination (IHA) test was positive with a titer of 1/1,024. The patient developed acute renal failure and died within 48 h of admission with multiple organ failure due to sepsis.