Theatre ventilation

INTRODUCTION

Owing to the COVID-19 pandemic, there has been significant disruption to all surgical specialties. In the UK, units have cancelled elective surgery and a decrease in aerosol generating procedures (AGPs) was favoured. Centres around the world advocate the use of negative pressure environments for AGPs in reducing the spread of infectious airborne particles. We present an overview of operating theatre ventilation systems and the respective evidence with relation to surgical site infection (SSI) and airborne pathogen transmission in light of COVID-19.

METHODS

A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Search terms included "COVID-19", "theatre ventilation", "laminar", "turbulent" and "negative pressure".

FINDINGS

Evidence for laminar flow ventilation in reducing the rate of SSI in orthopaedic surgery is widely documented. There is little evidence to support its use in general surgery. Following previous viral outbreaks, some centres have introduced negative pressure ventilation in an attempt to decrease exposure of airborne pathogens to staff and surrounding areas. This has again been suggested during the COVID-19 pandemic. A limited number of studies show some positive results for the use of negative pressure ventilation systems and reduction in spread of pathogens; however, cost, accessibility and duration of conversion remain an unexplored issue. Overall, there is insufficient evidence to advocate large scale conversion at this time. Nevertheless, it may be useful for each centre to have its own negative pressure room available for AGPs and high risk patients.

Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises in the early management of urinary incontinence after radical prostatectomy

OBJECTIVE

To evaluate the comparative effectiveness of electromyographic (EMG) biofeedback with verbal instructions as learning tools of pelvic muscle exercises (PMEs) in the early management of urinary incontinence after radical prostatectomy.

PATIENTS AND METHODS

Forty-two consecutive patients (mean age 64 years, sd 4.2), with urinary incontinence after radical retropubic prostatectomy for localized prostate cancer, were randomized to receive biofeedback (group A, 28 men) or verbal feedback (group B, 14 men) as learning tools for PMEs immediately after catheter removal. Group A received 15 sessions of EMG biofeedback (three times weekly, 30 min each) and group B verbal instructions. Evaluation at baseline and 1, 2, 3 and 6 months included the 1-h pad-test and a questionnaire (number of pads/day and incontinence episodes).

RESULTS

By the last follow-up, 27 patients had received biofeedback and 15 verbal instructions. Data were analysed according to the intention-to-treat principle. Urine loss as assessed by the 1-h pad-test at baseline, 1, 2, 3 and 6 months was 39, 18, 7, 4 and 3 g for group A and 31, 11, 3, 1 and 0 g for group B, respectively (P > 0.05). The number of pads/day was 3.9, 3.4, 1.2, 0.8 and 0.4 for group A and 3.6, 1.8, 0.9, 0.4 and 0.2 for group B, respectively (P > 0.05). The overall continence rate at 6 months was objectively (urine loss > 1 g) 91% and subjectively (0-1 pad/day) 95%.

CONCLUSION

Intensive verbal instructions and biofeedback were both very effective behavioural methods and learning tools for PMEs in the early management of urinary incontinence after radical prostatectomy.

Incontinence after surgery for benign prostatic hypertrophy: the case for complex approach and treatment

OBJECTIVE

Whether incontinence after surgery for benign prostatic hypertrophy (BPH) requires simple workup and treatment or being a more complex condition and multifactorial in etiology requiring combined surgical techniques should be investigated in more detail.

METHODS

We retrospectively reviewed the records of 56 patients referred to us for post-prostatectomy incontinence after surgery for BPH. All patients were subjected to urodynamics. Twenty-three (41.1%) patients required additional ascending urethrogram and/or cystourethroscopy, according to their associated symptomatology and the urodynamic findings, for a definitive diagnosis to be established.

RESULTS

Twenty-four patients (42.8%) were found to have complex incontinence (either mixed or any type associated with bladder outlet stenosis), requiring combined treatment. Twenty-three (41.1%) had a simple type of incontinence, i.e., pure sphincter incompetence or unstable detrusor. Three patients had residual adenoma and 1 urethral stricture, while 5 patients (8.9%) remained unclassified. Thirty-seven patients were subjected to treatment, 27 (73%) of them to single-modality treatment (artificial urinary sphincter insertion, oxybutynin chloride, transurethral prostatectomy, optical urethrotomy) and the other 10 (27%) to combined treatment (artificial urinary sphincter insertion plus urethroplasty, ileocystoplasty, permanent urethral stent implantation etc.). The overall socially acceptable continence rate (cured plus significantly improved) of the patients subjected to artificial urinary sphincter insertion reached 85%, being better (90%) for the uncomplicated sphincter incompetence group.

CONCLUSIONS

Incontinence after surgery for BPH represents a condition that requires careful evaluation. In a significant proportion of patients, a combination of prosthetic and reconstructive techniques is needed for an optimal result to be achieved.

The urodynamic profile of prostatodynia

OBJECTIVE

To evaluate urodynamically patients with prostatodynia, and thus define a specific urodynamic pattern that might add to the pathophysiology of the syndrome and possibly aid definitive treatment.

PATIENTS AND METHODS

Forty-three patients (mean age 38.1 years, sd 9.25, range 24-59) with symptoms suggestive of chronic prostatitis, e.g. dysuria, frequency of micturition and a burning sensation in the perineum, were classified as having prostatodynia after excluding prostatic infection by standard bacteriological methods. Thereafter, the patients were evaluated urodynamically, including the measurement of free flow-rate, filling (water) cystometry, a pressure/flow study of micturition, with fluoroscopy and electromyography of the external urethral sphincter.

RESULTS

Twenty-eight patients (65%) had a low maximum free flow rate (Qmax ), with a mean (sd) of 10.91 (1.26) mL/s. Of the 42 patients who underwent filling cystometry, 26 (62%) had a first sensation of filling, and 28 (67%) a first desire to void, at low volumes (<150 mL and <300 mL, respectively). Of the 25 patients who underwent a pressure/flow study, 16 (64%) had an obstructive pattern of micturition, as defined by a low Qmax of 10.04 (1.38) mL/s and a high intravesical pressure at Qmax of 83.3 (5.3) cmH2O. The site of obstruction was at the level of the bladder neck, as confirmed by fluoroscopy.

CONCLUSION

A significant proportion of these patients had a particular urodynamic pattern of functional infravesical obstruction at the level of the bladder neck and sensory disturbances.

A comparison of the Sport Stirrup, Malleoloc, and Swede-O ankle orthoses for the foot-ankle kinematics of a rapid lateral movement

Little information exists about the efficacy of various brace designs to restrict inversion during lateral movements. The purpose of the study was to determine whether semi-rigid stirrup (AirCast Sport Stirrup), semi-rigid modified stirrup (Malleoloc), or a soft, sleeve design (Swede-O) brace varied in their abilities to restrict inversion without hindering plantar/dorsiflexion when a lateral cutting movement is performed compared to a no-brace condition (No-Br). Nineteen volunteers who had previously sprained their right ankles performed 10 sideward cutting trials/brace condition. Based on kinematic data, captured using high-speed cameras, none of the braces restricted inversion compared to the No-Br condition. Plantar flexion was inhibited for all braces, and less dorsiflexion was exhibited for the Swede-O. For three participants, greater toe-in landings were observed for the Swede-O. Based on chi-square analyses, the participants rank of braces for stability and overall performance in decreasing order: Malleoloc, AirCast, Swede-O. It was concluded that the participants may have exhibited injury avoidance behavior during conditions perceived to be less stable, thereby reducing inversion when wearing no brace or the Swede-O brace. It also is tenable that the motion of the shoe was influenced by the presence of the braces, hence, no inversion restriction was observed.

Neurogenic bladder dysfunction due to Behçet's disease

BACKGROUND

Behcet's disease is a chronic multisystem condition of unknown origin. Genitourinary tract involvement with genital apthous ulcers, epididymitis, urethritis and recurrent cystitis is encountered commonly. Neurogenic bladder dysfunction due to neural involvement of the syndrome, has been reported extremely rarely.

METHODS

A case of neurogenic bladder dysfunction due to Behcet's disease is presented. The patient was 17-year-old young male with a long history of the disease and neurological affection, but with neglected lower urinary tract symptoms and urinary incontinence. The patient was diagnosed urodynamically to have hyperreflexic detrusor.

RESULTS/DISCUSSION

After failure of medical treatment (oxybutynin chloride) the patient submitted to augmentation clam-type sigmoidocystoplasty. Four years postoperatively, the patient is dry, on clean intermittent self catheterization twice daily and he is practically asymptomatic from lower urinary tract symptoms.

Can p53 nuclear over-expression, Bcl-2 accumulation and PCNA status be of prognostic significance in high-risk superficial and invasive bladder tumours?

AIMS

To evaluate p53 and Bcl-2 expression and proliferating status (PCNA) in subgroups of patients with high-risk superficial and invasive bladder cancer, with relation to cancer progression and death, and to correlate the results with established clinical prognostic factors.

METHODS

Paraffin-embedded sections from 42 high-risk superficial (T1G2,T1G3) and 33 invasive (T2-T4aG3 N0M0) tumours were investigated immunohistochemically for p53, Bcl-2 and PCNA. The median follow-up was 52 months.

RESULTS

In the cohort of superficial tumours, statistical analysis showed that p53 and PCNA positivity were significant prognostic factors (P-values: 0.008 and 0.006, respectively) for disease-specific death (DSD). When life expectancy was evaluated (log-rank test), p53(+) (P = 0.015) and PCNA(+) (P = 0.017) offered the most accurate prognosis compared to grade, tumour size and multiplicity. Bcl-2 status had no significant effect on patient survival. In the subset of muscle-invasive tumours we failed to demonstrate any important role of p53, Bcl-2 or PCNA positivity.

CONCLUSIONS

p53 and PCNA over-expression may offer valuable additional prognostic information in high-risk subgroups of superficial bladder tumours. From our results, Bcl-2 does not appear to contribute significantly to the prognosis of these patients. None of the studied markers offered prognostic information in muscle-invading disease.

Incidence and histological findings of unsuspected prostatic adenocarcinoma in radical cystoprostatectomy for transitional cell carcinoma of the bladder

OBJECTIVE

The present study is designed to evaluate the incidence, histological features and significance of prostatic adenocarcinoma in patients undergoing cystoprostatectomy for Transitional Cell Carcinoma (TCC) of the bladder.

PATIENTS, MATERIAL AND METHODS

From January 1990 to December 1996, 59 male patients (mean age 66.5 years), with no evidence of prostatic malignancy on preoperative clinical and biochemical assessment, underwent cystoprostatectomy for TCC of the bladder. The bladder was adequately sampled and the entire prostate sectioned at 5-mm intervals and examined histologically, in order to identify unsuspected prostatic cancer (PCa).

RESULTS

Sixteen out of 59 patients (27%) were found to have PCa, which was multifocal in 5 cases (31.25%). The mean tumor size was 0.24 cm. The tumors were equally distributed in the anterior and posterior parts of the prostate and in the peripheral and transition zones, with uniform distribution in both prostatic lobes. In 5 patients (31.25%), the single focus of the tumor was in the apex. All were grade I tumors except one, and all were organ-confined with no capsular penetration. The follow-up ranged from 12-74 months (mean 39 months). Within this period, 7 patients died from metastatic bladder cancer. One patient with PCa localized in the prostatic apex had recurrent prostatic disease in the urethro-ileal anastomosis of an orthotopic bladder substitute; he is alive and on androgen deprivation. The remaining patients are relapse-free.

CONCLUSIONS

Incidental PCa is quite a common finding in cystoprostatectomy specimens of bladder cancer patients. Its tendency to appear in the apex of the prostate demands careful and complete excision of the organ.

Lower urinary tract reconstruction in association with renal transplantation

Congenital or acquired dysfunction of the lower urinary tract may result in renal failure. In this group of patients urinary diversion or lower urinary tract reconstruction is mandatory prior to renal transplantation. Avoiding creation of an external stoma offers far more better quality of life to these unfortunate patients. We present three patients in end-stage renal disease. Two of them presented with dysfunction of the lower urinary tract and the third with absence of the bladder. Reconstruction or substitution of their bladders has been performed prior to kidney transplantation. In one patient an artificial urinary sphincter was implanted simultaneously in order to achieve continence, while all the patients have to empty their neobladders or augmented bladders by clean intermittent self-catheterization. In conclusion, dysfunction or absence of the lower urinary tract does not preclude renal transplantation and however abnormal the urinary tract, transplantation can still be performed if low-pressure, high-compliance reservoir can be achieved by means of augmentation or substitution cystoplasty.

Combined reconstructive and prosthetic surgery in complicated lower urinary tract dysfunction

PURPOSE

The combined use of the appropriate reconstructive technique and available prosthetic material was evaluated to achieve an optimal functional result in complicated lower urinary tract dysfunction.

MATERIALS AND METHODS

The study included 16 male and 8 female patients. Urinary dysfunction was classified into 2 main categories: 1) neuropathic and 2) nonneuropathic. Of the patients 22 underwent some form of augmentation (21) or substitution (1) cystoplasty, 24 received an artificial urinary sphincter, 2 underwent abdominoperineal urethroplasty and 2 received a permanent urethral stent. One patient underwent renal transplantation and 1 received a penile prosthesis for concurrent impotence.

RESULTS

A total of 20 patients (83.3%) became continent, 10 void spontaneously, while 14 must empty the bladder or pouch by clean intermittent self-catheterization. All patients have stable or improved renal function.

CONCLUSIONS

Combined reconstructive and prosthetic surgery has an important role in the treatment of lower urinary tract dysfunction, with a high success rate and good quality of life.

Is beta-human chorionic gonadotrophin production by transitional cell carcinoma of the bladder a marker of aggressive disease and resistance to radiotherapy?

The biopsies from 75 patients with transitional cell carcinoma of the bladder (25 Ta-T1; 45 T2-T4, 5M) were studied immunohistochemically for the expression of beta-human chorionic gonadotrophin (beta-HCG). Only 5 Ta-T1 tumours contained a small number of beta-HCG positive cells but 24 invasive tumours and all patients with metastases showed increased numbers of positive cells. A significant correlation was found between beta-HCG immunoreactivity and tumour category. In 30 patients with muscle-invasive disease (T2-T4,N0,M0) who were treated with radical radiotherapy a significant correlation was observed between response to treatment and beta-HCG expression; beta-HCG positive tumours did not respond to treatment. A difference in survival was found between patients with tumours negative for beta-HCG compared with patients with positive tumours, all treated with radical radiotherapy. The results indicate that beta-HCG expression increases with tumour invasiveness and the use of immunohistochemistry may prove a useful means of identifying radioresistant and aggressive forms of bladder cancer.

Coronary-heart-disease risk-factor status of the Cretan urban population in the 1980s

The traditional Cretan diet has been associated with low coronary-heart-disease (CHD) mortality rates. This study reports on the prevalence of CHD risk factors among 387 Cretan bank employees. Mean cholesterol concentration has risen by 36% over 26-y; dietary intake has changed: consumption of meat, fish, and cheese has increased and consumption of bread, fruit, and potatoes has decreased. Although the percentage contribution of fat to total energy intake has decreased from 40% to 36%, there has been a reduction in monounsaturated fatty acid consumption and an increase in the consumption of saturated fatty acids whereas the consumption of polyunsaturates has not been altered. Exception for diminished physical activity, the prevalence of other risk factors (smoking, blood pressure, and body mass index) remained relatively stable over this period. These changes in the CHD risk-factor status of the Cretan urban population occurred over a period in which CHD mortality rates are reported to have increased.

Prostatic-type epithelium in urinary bladder. Clinical, histologic, and immunohistochemical study

Six cases of urinary bladder mucosa with prostate-type epithelium were studied clinically, morphologically, and immunohistochemically. All patients were male with an average age of fifty-three years; most presented with painless hematuria. Histologically, two types of lesions were observed, the polypoid located in various sites of the bladder wall and the flat lesion found in the bladder neck. Both lesions shared in common a prostatic-type and transitional surface epithelium while prostatic-type glands were prominent in the polypoid lesion. The prostatic-type epithelium was confirmed immunohistochemically by detection of prostatic specific antigen and prostatic acid phosphatase. Based on specific findings we considered the metaplasia as the most reliable histogenetic aspect.

The reduction of root colonization by mycorrhizal fungi by mycophagous amoebae

Two mycophagous amoebae, Saccamoeba sp. and Gephyramoeba sp., reduced the colonization of pine roots in soil by the ectomycorrhizal fungus, Rhizopogon luteolus, when added at the same time as the fungus or 2 weeks later. Another mycophagous amoeba, an unidentified leptomyxid, was unable to do so. When seedlings were grown in sterilized soil amended with different population levels of Saccamoeba, 42 and 85 amoebae g soil−1 had no effect but large reductions in root colonization by R. luteolus occurred when 430 and 860 amoebae g soil−1 were added. After 4 weeks, however, the protozoa population increased to a similarly high level in all treatments irrespective of the numbers added initially. Our results indicate that protozoa can have a large effect on the establishment of inoculated symbiotic fungi and could markedly affect the microbial composition of the rhizosphere.

Intravesical methotrexate in the treatment of superficial bladder cancer

Thirty patients with superficial bladder cancer (Tis, Ta, Tl) difficult to control by endoscopic means were given a total of 49 courses of methotrexate at fortnightly intervals. Four concentrations were investigated. In 14 courses this was the sole treatment and in the remainder the methotrexate was given as prophylaxis. Toxicity was not a problem but in both groups, although there was some evidence of anti-tumour activity, there were high recurrence rates and intravesical methotrexate cannot be recommended.

Sensitivity of exfoliative cytology in bladder cancer using the divided one-urine specimen examination

The urine of 104 patients with bladder cancer was examined by exfoliative cytology. Three staining methods (Giemsa, Papanicolaou and Oil Red O) were used and the results compared with the histological diagnosis. Giemsa was found to be superior to the other two methods but the highest sensitivity (which was statistically significant) was obtained by a combination of the three methods.

Treatment of bladder carcinoma with irradiation combined with misonidazole

One hundred patients suffering from cancer of the bladder were treated by external beam irradiation, 400 cGy twice a week to a total dose of 4800 cGy. One half of the patients were randomized to receive the electron affinic sensitizer agent, misonidazole, at a dose of 1 gr/m2 and a total dose of 12 gr/m2. There was no statistically significant difference in tumor responses and in recurrence--free survival time between the patients who received irradiation and misonidazole as compared to those who received irradiation and placebos.