Bipolar versus monopolar transurethral resection of the prostate: a prospective randomized trial focusing on bleeding complications.

PURPOSE: We compare monopolar vs bipolar transurethral resection of the prostate in patients with benign prostatic hyperplasia, focusing on functional outcomes as well as rates of bleeding complications and the transurethral resection syndrome. MATERIALS AND METHODS: A total of 137 patients with benign prostatic hyperplasia (mean age 67 years, range 47 to 91) were prospectively randomly assigned to undergo monopolar (67) or bipolar (70) transurethral resection of the prostate. Patient characteristics of the 2 groups were similar. Hemoglobin (as a marker of blood loss) was measured preoperatively and perioperatively. I-PSS, I-PSS-QoL score, maximal flow rate and post-void residual urine volume were assessed preoperatively and 3 and 12 months postoperatively. Duration of surgery, indwelling catheter use and hospitalization were also documented, as were postoperative clot retention requiring removal by catheterization or surgery, and rates of bladder neck and/or urethral strictures. RESULTS: No significant perioperative differences were found in duration of surgery, catheterization or hospitalization, or in blood loss or rates of blood transfusion and transurethral resection syndrome. Postoperatively there were no significant differences in I-PSS or I-PSS-QoL scores, or rates of rehospitalization, clot retention, blood transfusions, reoperation or urethral strictures. However, bladder neck stricture occurred significantly more often in the bipolar group (8.5% vs 0%, p = 0.02). The 3 and 12-month followup showed significant and equal improvement in micturition in the 2 groups. CONCLUSIONS: Bipolar and monopolar transurethral resection of the prostate are effective and safe techniques for the surgical treatment of benign prostatic hyperplasia. The only significant difference between them was a significantly higher rate of bladder neck strictures with bipolar resection of the prostate.

One- vs 4-week stent placement after laparoscopic and robot-assisted pyeloplasty: results of a prospective randomised single-centre study.

OBJECTIVES: To determine whether 1-week stenting of the pelvi-ureteric anastomosis of laparoscopic or robot-assisted pyeloplasty is as effective as 4-week stenting, based on their respective success rates. PATIENTS AND METHODS: A total of 100 patients with pelvi-ureteric junction obstruction were treated by Anderson-Hynes pyeloplasty and the anastomosis was stented using a 6-F JJ catheter for either 1 week (1W series) or 4 weeks (4W series), based on a randomisation protocol. Postoperative follow-up was performed at 3 months using intravenous urography (IVU), at 6 months using diuretic renography and at 1, 3 and 5 years using ultrasonography. Statistical analysis was performed using a one-sided Z-test, Pearsons's chi-squared test and a Wilcoxon rank sum test. RESULTS: The primary outcome measure, success rate, which was defined as no obstruction on IVU and diuretic renography, was 100% in the 1W series and not inferior to the success rate of 98% in the 4W series (P = 0.006). The following secondary outcome measures were not significantly different between the 1W and the 4W series with regard to residual symptoms (10 vs 6%; P = 0.48), rate of complications (4 vs 6%; P = 0.65), need for synchronous robot-assisted pyelolithotomy (4 vs 8%; P = 0.47), improvement in split renal function (1 vs 0%; P = 0.59) and duration of surgery (200 vs 192 min; P = 0.87). Only length of hospital stay was significantly different; this was shorter in the 1W series (5 vs 6 days; P = 0.01). CONCLUSIONS: Stenting of the pelvi-ureteric anastomosis after laparoscopic or robot-assisted pyeloplasty for 1 week is as effective as stenting for 4 weeks. Both procedures, laparoscopic or robot-assisted pyeloplasty have an excellent success rate.

When and how should we test the tightness of the vesicourethral anastomosis after retropubic radical prostatectomy?

OBJECTIVE: To determine when the vesicourethral anastomosis (VUA) becomes tight after retropubic radical prostatectomy (RRP) and if an additional lateral view cystography provides significantly more information than the only anterior-posterior view. PATIENTS AND METHODS: Pressure-controlled cystography with anterior-posterior and lateral views was performed on postoperative days (POD) 3, 6 and 9 and evaluated in 100 consecutive patients after RRP. RESULTS: On POD 3, 6 and 9, 82, 80 and 82% of all VUA, respectively, were tight. 85% of all tight VUA on POD 3 remained tight on POD 6 and 9. Of the 52 extravasations in a total of 300 cystographies, 65% were recognizable in the anterior-posterior as well as in the lateral view cystography, 6% were seen only in the anterior-posterior view and 29% only in the lateral view. CONCLUSIONS: The VUA after RRP is tight in about 80% of the cases on POD 3, 6 and 9. A tight VUA on POD 3 does not exclude later extravasation on POD 6 and 9 (14%). About one third (29%) of all extravasations of VUA are seen only in the lateral view cystography after RRP.

[Management of pediatric septic shock]. / Prise en charge du choc septique chez l'enfant.

Septic shock is a frequent admission cause in intensive care unit. In spite of the important progresses in the understanding of his physiopathology, mortality due to septic shock is about 20%. Recently, it has been demonstrated that an early goal-directed therapy permitted to improve the patient prognosis. With a good hemodynamic management and early antibiotherapy, mortality could be reduced.

[Starting experience with non-invasive ventilation in paediatric intensive care unit]. / Ventilation non invasive en réanimation pédiatrique: un début d'expérience.

Non-invasive ventilation in pressure support (NIV) is well described in the adult and child over 5 years. However, its use in children less than 1 year of age remains anecdotal. We report our preliminary experience with the use of NIV in six children aged from 5 days to 10 months. NIV was delivered with a flow generator (VPAP IIST, Resmed Ltd, North Ryde, NSW, Australia) in association with specific tubings and a nasal mask. The use of NIV resulted in a significant decrease of both the respiratory rate (from 53 to 39 breaths per min, p < 0.01) and the PvCO(2) (from 9.33 to 6.28 kPa, p < 0.01). These results show that NIV can be used in children under 1 year of age with improvement of physiological parameters.

[Acute respiratory distress syndrome in children]. / Le syndrome de détresse respiratoire aiguë (SDRA) chez l'enfant.

The acute respiratory distress syndrome (ARDS) encountered in a child may be either due to a primary lung infection or may be secondary to a systemic inflammatory response of varying origin. Therapy is based on: 1) the mechanical ventilation strategy aimed at maintaining the functional residual capacity by alveolar recruitment using positive end expiratory pressure and to limit secondary pulmonary lesions by using small tidal volumes, 2) prone positioning as soon as sufficient stability is achieved; 3) optimizing tissue oxygen delivery by cardiac support; 4) correction of any other organ dysfunction. If this conventional approach is not sufficient experimental therapies may be tempted given the vital risk. For instance inhaled nitric oxide and high frequency oscillation ventilation may be a valuable support. Newer techniques, such as partial liquid ventilation, are being developed and could become useful therapeutic options. After the acute phase a close medical follow-up is mandatory. Because of the possibility of a chronic respiratory insufficiency with negative consequences on the right ventricular function, these patients may need long term oxygen therapy and diuretics. Cardiac echography helps orientation in maintaining or discontinuing this long term therapy by estimating the arterial pulmonary pressure.

[Carbon monoxide poisoning in children: never trivialize]. / Intoxication par le monoxyde de carbone chez l'enfant: ne jamais banaliser.

The risks linked to tissular hypoxemia after carbon monoxide (CO) poisoning are well known. Unawareness of CO exposure and of its complex pathophysiology may delay appropriate treatment and lead to long term neuropsychological sequelae. We report two cases of children treated in our institution and review the main issues regarding the optimal management. A high index of suspicion for carbon monoxide poisoning when dealing with an unclear neurological clinical presentation is mandatory. Classical therapy with normobaric 100% oxygen has to be instaured immediately. Hyperbaric oxygen therapy must be considered when anamnestic symptoms or clinical signs suggest neurological involvement even when carboxyhemoglobin values are low or already normalized.

A new filtering algorithm for medical magnetic resonance and computer tomography images.

Inner views of tubular structures based on computer tomography (CT) and magnetic resonance (MR) data sets may be created by virtual endoscopy. After a preliminary segmentation procedure for selecting the organ to be represented, the virtual endoscopy is a new postprocessing technique using surface or volume rendering of the data sets. In the case of surface rendering, the segmentation is based on a grey level thresholding technique. To avoid artifacts owing to the noise created in the imaging process, and to restore spurious resolution degradations, a robust Wiener filter was applied. This filter working in Fourier space approximates the noise spectrum by a simple function that is proportional to the square root of the signal amplitude. Thus, only points with tiny amplitudes consisting mostly of noise are suppressed. Further artifacts are avoided by the correct selection of the threshold range. Afterwards, the lumen and the inner walls of the tubular structures are well represented and allow one to distinguish between harmless fluctuations and medically significant structures.

The value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections.

The purpose of this study was to assess the importance of stereolithographic models (SLMs) for preoperative diagnosis and planning in craniofacial surgery and to examine whether these models offer valuable additional information as compared to normal CT scans and 3D CT images. Craniofacial SLMs of 20 patients with craniomaxillofacial pathology were made. A helical volume CT scan of the anatomic area involved delivered the necessary data for their construction. These were built with an SLA 250 stereolithography apparatus (3D-Systems, Valencia, CA, USA), steered by FORM-IT/DCS software (University of Zurich, Switzerland). The stereolithography models were classified according to pathology, type of surgery and their relevance for surgical planning. Though not objectively measurable, it was beyond doubt that relevant additional information for the surgeon was obtained in cases of hypertelorism, severe asymmetries of the neuro- and viscerocranium, complex cranial synostoses and large skull defects. The value of these models as realistic "duplicates" of complex or rare dysmorphic craniofacial pathology for the purpose of creating a didactic collection should also be emphasized. The models proved to be less useful in cases of consolidated fractures of the periorbital and naso-ethmoidal complex, except where there was major dislocation.

[Preoperative diagnosis of complex craniofacial syndromes]. / Präoperative Diagnostik komplexer kraniofazialer Syndrome.

The aim of this study was to evaluate stereolithography as a tool in craniofacial surgery. The indications were classified according to the usefulness of stereolithography for different craniofacial pathologies. Stereolithography models of 21 patients were built; in three cases two models were made. The age of the 7 male and 14 female patients was 17 years on average (range: 15 months-44 years). First a helical volume CT scan of the anatomical region was performed. After transformation of the data set, the models were built by an SLA 250 stereolithography apparatus (3D-Systems, Valencia, Calif., USA), steered by FORM-IT/DCS-Software (University of Zurich, Switzerland). The stereolithography models were constructed by superposition of epoxy resin slices of 0.05 mm thickness, which were polymerized by a helium-cadmium laser. These models were classified according to the indication for stereolithography, the operation performed, the relevance for surgical planning and the usefulness for the fabrication of implants and protheses. In craniofacial syndromes, severe asymmetries of the viscerocranium, large skull defects and before surgical correction of hypertelorism these models provided important additional information for the surgeon. Before complex interventions in these fields the construction of a stereolithography model should be considered. In multiple fractures consolidated in dislocation, the models proved to be less useful.

[Pre-operative diagnosis of complex craniofacial syndromes]. / Präoperative Diagnostik komplexer kraniofazialer Syndrome.

The aim of this study was to evaluate stereolithography as a tool in craniofacial surgery. The indications were classified according to the usefulness of stereolithography for different craniofacial pathologies. Stereolithography models of 21 patients were built; in three cases two models were made. The age of the 7 male and 14 female patients was 17 years on average (range: 15 months-44 years). First a helical volume CT scan of the anatomical region was performed. After transformation of the data set, the models were built by an SLA 250 stereolithography apparatus (3D-Systems, Valencia, Calif., USA), steered by FORM-IT/DCS-Software (University of Zurich, Switzerland). The stereolithography models were constructed by superposition of epoxy resin slices of 0.05 mm thickness, which were polymerized by a helium-cadmium laser. These models were classified according to the indication for stereolithography, the operation performed, the relevance for surgical planning and the usefulness for the fabrication of implants and protheses. In craniofacial syndromes, severe asymmetries of the viscerocranium, large skull defects and before surgical correction of hypertelorism these models provided important additional information for the surgeon. Before complex interventions in these fields the construction of a stereolithography model should be considered. In multiple fractures consolidated in dislocation, the models proved to be less useful.

An intra-operative seminal and prostate emission test as a control for nerve-sparing procedures in primary and secondary retroperitoneal lymphadenectomy.

OBJECTIVE: To determine the value of an intra-operative electrostimulatory test of post-ganglionic nerves for the preservation of ejaculation in primary and secondary retroperitoneal lymph-node dissection (RLND). PATIENTS AND METHODS: Between 1991 and 1994, 21 patients with non-seminomatous testicular cancer of clinical stage A and 15 patients with bulky or clinical stage C disease underwent primary or secondary RLND, respectively. During surgery, post-ganglionic nerves were electrostimulated at 30 Hz and up to 20 V, for 3-10 s. Emissions were recorded simultaneously by suprapubic ultrasonography of the seminal vesicals and bladder neck (in 36 patients) and by endoscopy of the posterior urethra (in 11 patients). RESULTS: A positive intra-operative emission test in 15 pathological stage A (with bilateral nerve-sparing) and six pathological stage B (with contralateral nerve-sparing) patients predicted the post-operative preservation of antegrade ejaculation. In the group undergoing secondary RLND, the test allowed the identification and sparing of the emission-related nerves in four of 15 patients with a residual mass consisting of necrosis/fibrosis, and preserved antegrade ejaculation after surgery. CONCLUSIONS: A positive result in the seminal emission test predicted the preservation of antegrade ejaculation after surgery. The test is not necessary in patients with clinical stage A disease, but improves the chances of reducing morbidity. If the residual mass consists of necrosis or fibrosis, then electrostimulation during secondary RLND can help to identify important nerve structures when their origin is unknown initially. However, attempts to retain nerve function must not jeopardize the patient's survival. The test can be an option for clinical stage B disease with initial bilateral RLND, to identify and preserve emission-relevant nerves while the retroperitoneal space is removed radically. The test may also give additional information about the physiology of emission.

Molecular cloning of a vitamin D-dependent calcium-binding protein mRNA sequence from chick intestine.

We have constructed a recombinant cDNA library to facilitate study of the genomic actions of vitamin D3 and its hormonally active metabolite 1,25-dihydroxyvitamin D3 in initiation of the de novo biosynthesis of a 28,000-dalton vitamin D-dependent calcium binding protein (CaBP) present in chick intestine. The recombinant plasmids were prepared by the homopolymeric tailing and hybridization method using as a starting template poly(A)-enriched mRNA obtained from the intestinal mucosa of vitamin D3-replete (+D) chicks. Screening of 9,516 clones in this library was effected by using a comparative in situ colony hybridization technique with two [32P]cDNA probes; these probes were prepared from total poly(A)-RNA from chick intestinal mucosa of vitamin D-deficient (-D) chicks and a poly(A)-RNA specifically enriched for chick intestinal CaBP mRNA by immunoprecipitation of polysomes derived from vitamin D-replete (+D) chicks. We identified 26 clones that consistently displayed a significantly increased hybridization signal when comparing the -D vs. CaBP-enriched probe. Further evaluation of these clones by hybrid-selected translation showed the presence of CaBP-specific sequences. By "RNA gel" analysis of poly(A)-RNA, three independent mRNA species were found to hybridize to a CaBP clone; none of these RNA species were found in -D poly(A)-RNA. With this comparative colony hybridization procedure, we were able to identify CaBP-specific clones corresponding to a mRNA that is 0.1% of the total poly(A)-mRNA. The differential colony hybridization procedure using an enriched vs. a nonenriched probe should be of value in screening for other cDNA clones complementary to rare mRNA species.

The response to potassium of the Na-K pump ATPase in low-K red blood cells from cattle at birth and in later life.

It is shown that in low-K red blood cells of cattle the apparent affinity for K(1/Kapp K) at an inhibitory site of the Na-K ATPase increases markedly during the first 3 months of life. This site probably is the Na accepting site at the internal membrane surface and the change in Kapp K reflects an increase in KNa/KK, the ratio of the true dissociation constants. This effect may explain the concomitant fall in cellular K concentration.

Digitoxin intoxication with severe thrombocytopenia: reversal by digoxin-specific antibodies.

As a result of overdosage a 77-year-old patient with heart disease developed digitoxin intoxication, associated with arrhythmias, extracardiac symptoms of intoxication and severe thrombocytopenia. Treatment with digoxin-specific antibody fragments relieved the signs and symptoms of intoxication within a few hours. The rise in platelet count from the pretreatment value of 26 000/mm3 to 47 000 within 12 h and to over 60 000/mm3 within 16 h of starting the antibody infusion may also be attributed to the treatment with antibodies. Such a rapid recovery from digitoxin-induced thrombocytopenia has not hitherto been described. Digoxin-specific antibodies, obtained by immunization of sheep with a digoxin-albumin conjugate, were used to treat intoxication with digitoxin, since cross-reaction had been demonstrated in vitro and in animal experiments. The present paper briefly discusses the mode of action and the general problems relating to the antibody therapy of digitalis poisoning.

[Drug side effects as the probable cause of death. Results of the Berne Comprehensive Hospital Drug Monitoring Program]. / Medikamentnebenwirkungen als wahrscheinliche Todesursache. Ergebnisse aus dem Komprehensiven Spital Drug Monitoring Bern (CHDMB).

During the years 1974-1980, 19 of 17,285 inpatients of the divisions of internal medicine of two teaching hospitals showed a probable or definite adverse drug reaction (ADR) which was considered to be a major cause of death. In 7 patients the decisive ADR occurred during the hospital stay. The overall mortality from ADR is 0.040%. For each therapeutic group of drugs the following rate of drug-related death was calculated: for anticoagulants 0.047% (3/6378 inpatients), for cardiac glycosides 0.016% (1/6368), for analgesic/antirheumatic drugs 0.014% (1/7112) and for cytostatic drugs 0.38% (2/531). In 12 patients the ADR was already present on hospital admission.