Geographic Accessibility and Completion of Initial Low-Dose CT-Based Lung Cancer Screening in an Urban Safety-Net Population

BACKGROUND

Recent modifications to low-dose CT (LDCT)-based lung cancer screening guidelines increase the number of eligible individuals, particularly among racial and ethnic minorities. Because these populations disproportionately live in metropolitan areas, we analyzed the association between travel time and initial LDCT completion within an integrated, urban safety-net health care system.

METHODS

Using Esri's StreetMap Premium, OpenStreetMap, and the r5r package in R, we determined projected private vehicle and public transportation travel times between patient residence and the screening facility for LDCT ordered in March 2017 through December 2022 at Parkland Memorial Hospital in Dallas, Texas. We characterized associations between travel time and LDCT completion in univariable and multivariable analyses. We tested these associations in a simulation of 10,000 permutations of private vehicle and public transportation distribution.

RESULTS

A total of 2,287 patients were included in the analysis, of whom 1,553 (68%) completed the initial ordered LDCT. Mean age was 63 years, and 73% were underrepresented minorities. Median travel time from patient residence to the LDCT screening facility was 17 minutes by private vehicle and 67 minutes by public transportation. There was a small difference in travel time to the LDCT screening facility by public transportation for patients who completed LDCT versus those who did not (67 vs 66 min, respectively; P=.04) but no difference in travel time by private vehicle for these patients (17 min for both; P=.67). In multivariable analysis, LDCT completion was not associated with projected travel time to the LDCT facility by private vehicle (odds ratio, 1.01; 95% CI, 0.82-1.25) or public transportation (odds ratio, 1.14; 95% CI, 0.89-1.44). Similar results were noted across travel-type permutations. Black individuals were 29% less likely to complete LDCT screening compared with White individuals.

CONCLUSIONS

In an urban population comprising predominantly underrepresented minorities, projected travel time is not associated with initial LDCT completion in an integrated health care system. Other reasons for differences in LDCT completion warrant investigation.

Diastereospecific arylation and cascade deconstructive amidation/thioesterification of readily available lactam-fused bromolactones

An intrinsic goal when designing synthetic methodology is to identify approaches whereby readily accessible precursors are converted into an array of products, which efficiently tap into new 3D-chemical space. In these studies, readily available bicyclic lactam-bromolactones have been interrogated in several fragment growth protocols by utilizing the halogen and lactone motifs as versatile linchpins for strategic construction of C-C, C-N, C-O, and C-S bonds. Diastereospecific C(sp3)-C(sp2) Kumada coupling of sterically imposing [5,5]-bicyclic lactam-bromolactones with several aryl Grignard reagents, under palladium catalysis, furnishes diarylmethane-tethered lactam-lactones in synthetically attractive yields, stereoinvertive fashion, and with a tolerance for many functional groups. When [5,6]-bicyclic lactam-bromolactones, which are prone to β-hydride elimination are employed, efficient arylation is observed only under Co(acac)3-catalyzed conditions. Importantly, these [5,6]-bicyclic lactam-bromolactones undergo retentive arylation, independent of the transition metal catalyst. A base-mediated cascade deconstructive amidation of the [5,6]-bicyclic lactam-bromolactones with primary aliphatic amines proceeds efficiently to afford epoxide-tethered lactam carboxamides, which bear four contiguous stereocenters. Furthermore, an unusual route to homoallylic thioesters has been uncovered through deconstructive contra-thermodynamic thioesterification of the lactam-fused bromolactone precursors.

Regiodivergent synthesis of sulfone-tethered lactam-lactones bearing four contiguous stereocenters

Sulfone-tethered lactones/amides/amines display a diverse spectrum of biological activities, including anti-psychotic and anti-hypertensive. Sulfones are also widely present in functional materials and fragrances. We therefore reasoned that a regiodivergent and stereocontrolled strategy that merges the sulfone, lactone, and lactam motifs would likely lead to the discovery of new pharmacophores and functional materials. Here, we report mild conditions for the sulfonyllactonization of γ-lactam-tethered 5-aryl-4(E)-pentenoic acids. The annulation is highly modular, chemoselective, and diastereoselective. With respect to regioselectivity, trisubstituted alkenoic acids display a preference for 5-exo-trig cyclization whereas disubstituted alkenoic acids undergo exclusive 6-endo-trig cyclization. The lactam-fused sulfonyllactones bear angular quaternary as well as four contiguous stereocenters. The products are post-modifiable, especially through a newly developed Co-catalyzed reductive cross-coupling protocol.

Atraumatic Splenic Rupture due to Chronic Myelomonocytic Leukemia Treated with Partial Splenic Artery Embolization

Splenic rupture can be categorized into two groups: traumatic and atraumatic. Traumatic rupture is frequently associated with blunt abdominal trauma, while atraumatic splenic rupture (ASR) is more uncommon and has been associated with both benign and malignant hematological disorders. In general, most cases of splenic rupture are managed with splenectomy, which carries significant mortality and morbidity; more recently, splenic artery embolization (SAE) has become a mainstay of management particularly after traumatic rupture. We describe a patient with chronic myelomonocytic leukemia (CMML) who presented to the emergency department for acute abdominal pain and was found to have an ASR. He underwent partial SAE, with postoperative complications of leukocytosis and tumor lysis syndrome (TLS) requiring rasburicase and allopurinol. On follow-up in clinic 2 months post-discharge, the patient was doing well on hydroxyurea, without need for further intervention at that time. In patients with hematologic malignancies presenting with abdominal pain and splenomegaly, it is important to consider ASR as a rare, but possible complication. To our knowledge, this is the only reported patient treated with SAE in the context of ASR from CMML, demonstrating that SAE can be an effective nonoperative strategy for treatment of CMML-associated ASR. This case report also highlights postoperative complications and management in this patient population, specifically a profound leukocytosis and TLS, for which close monitoring should be performed.

PUMA - pooled uranium miners analysis: cohort profile

OBJECTIVES

Epidemiological studies of underground miners have provided clear evidence that inhalation of radon decay products causes lung cancer. Moreover, these studies have served as a quantitative basis for estimation of radon-associated excess lung cancer risk. However, questions remain regarding the effects of exposure to the low levels of radon decay products typically encountered in contemporary occupational and environmental settings on the risk of lung cancer and other diseases, and on the modifiers of these associations. These issues are of central importance for estimation of risks associated with residential and occupational radon exposures.

METHODS

The Pooled Uranium Miner Analysis (PUMA) assembles information on cohorts of uranium miners in North America and Europe. Data available include individual annual estimates of exposure to radon decay products, demographic and employment history information on each worker and information on vital status, date of death and cause of death. Some, but not all, cohorts also have individual information on cigarette smoking, external gamma radiation exposure and non-radiological occupational exposures.

RESULTS

The PUMA study represents the largest study of uranium miners conducted to date, encompassing 124 507 miners, 4.51 million person-years at risk and 54 462 deaths, including 7825 deaths due to lung cancer. Planned research topics include analyses of associations between radon exposure and mortality due to lung cancer, cancers other than lung, non-malignant disease, modifiers of these associations and characterisation of overall relative mortality excesses and lifetime risks.

CONCLUSION

PUMA provides opportunities to evaluate new research questions and to conduct analyses to assess potential health risks associated with uranium mining that have greater statistical power than can be achieved with any single cohort.

Uncertainties associated with assessing Ontario uranium miners' exposure to radon daughters

The Ontario uranium miners study is a large (n = 28 546) cohort with low levels of radon exposure relative to other uranium miner cohorts. Multiple methods were used over time to estimate annual occupational exposure to radon daughters including: mine-specific extrapolations by mining engineers, area sampling in limited areas of the mines combined with approximate working time and lastly, consistent exposure sampling in different locations of the mine combined with workers' time cards. Nonetheless, estimating exposures involves assumptions that lead to some uncertainty in occupational exposure characterisation arising from the assessment approach and variability within workplace, over time and by individual. An evaluation of the total uncertainty associated with radon daughter exposure estimation in Ontario miners over time has not been conducted. The objective of this study was to identify the contributing sources and assess the total uncertainty associated with estimating occupational radon daughter exposure among underground Ontario uranium miners over the course of uranium mining. The five sources of radon daughter exposure uncertainty evaluated were: natural variations in radon concentration, estimation of working time, precision of the radon measurement method, unintended errors during sampling, and record keeping and transcription of exposure data. These sources were examined separately for the period 1958 to 1967 and then 1968 onward due to changes in radon daughter concentration measurement practices between these periods. The magnitude of uncertainty associated with each of these sources over time were determined by reviewing historical literature on uranium mining in Ontario as well as through expert advice. Using the root sum square method, the total radon daughter exposure uncertainty was found to be 53 to 67% in the earlier period of uranium mining from 1958 to 1967. This decreased to 31 to 39% for the period 1968 to 1996 with natural variations of radon daughter concentrations in mines accounting for the largest percentage of uncertainty. This assessment provides an initial step in understanding the effect of exposure uncertainty on risk estimates. The impact of this uncertainty on the dose-response relationship between radon exposure and cancer risk will be assessed in future work.

Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

Objectives

To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP).

Methods

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be ≥6 months.

Results

In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of −0.30 days (95% confidence interval [CI] −0.35, −0.24) for the laparoscopic group and 1.09 days (95% CI −1.47, −0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01).

Conclusion

This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate.

Cancer incidence and mortality from exposure to radon progeny among Ontario uranium miners

OBJECTIVES

The study objectives were to extend the follow-up of the Ontario uranium miners cohort, one of the largest cohorts of uranium miners with low cumulative exposures, to examine the relationship between radon exposure and lung cancer mortality and, for the first time incidence, and address gaps in the literature, including dose-response relationship between radon exposure and other cancer sites, and non-cancer mortality.

METHODS

The cohort of mine and mill workers was created using data from Canada's National Dose Registry and the Ontario Mining Master File. The follow-up for the cohort was recently extended for mortality (1954-2007) and for the first time includes cancer incidence (1969-2005). The Poisson regression was used to estimate relative risks (RR) and excess relative risks (ERR) and their 95% CIs with levels of cumulative radon exposure.

RESULTS

The cohort consisted of 28 546 male miners with a mean cumulative radon exposure of 21.0 working level months (WLM). An increased risk of lung cancer and a dose-response relationship was observed with cumulative radon exposure. Miners exposed to >100 WLM demonstrated a twofold increase in the risk of lung cancer incidence (RR=1.89, CI 1.43 to 2.50) compared with the non-exposed group, and a linear ERR of 0.64/100 WLM (CI 0.43 to 0.85), with similar results observed for mortality. No association was observed for other cancer sites (stomach, leukaemia, kidney and extrathoracic airways) or non-cancer sites (cardiovascular diseases) with increasing cumulative exposure to radon.

CONCLUSIONS

These findings suggest no increased risk of cancer sites other than lung or non-cancer mortality from relatively low cumulative exposure to radon.

Robot-assisted technique for Boari flap ureteric reimplantation: replicating the techniques of open surgery in robotics

OBJECTIVE

To describe our robot-assisted Boari flap ureteric reimplantation (RA-BFUR) technique, Please see Video S1.

METHODS

The RA-BFUR technique is based on the open surgical technique of Übelhör, and the experience includes 11 cases.

RESULTS

Excellent results were achieved after a mean follow-up period of >12 months.

CONCLUSION

The RA-BFUR technique could be considered a safe and effective method of ureteric reimplantation for long distal ureteric strictures.

Robot-assisted laparoscopic total extraperitoneal hernia repair during prostatectomy: technique and initial experience

Introduction

To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes.

Material and methods

12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure.

Results

Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data.

Conclusions

Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

Non-invasive estimation of prostate cancer aggressiveness using diffusion-weighted MRI and 3D proton MR spectroscopy at 3.0 T

BACKGROUND

Clinical management of prostate cancer increasingly aims to distinguish aggressive types that require immediate and radical treatment from indolent tumors that are candidates for watchful waiting. This requires reliable and reproducible parameters to effectively control potential cancer progression. Magnetic resonance imaging (MRI) may provide a non-invasive means for this purpose.

PURPOSE

To assess the value of diffusion-weighted imaging and proton MR spectroscopy for the prediction of prostate cancer (PCa) aggressiveness.

MATERIAL AND METHODS

In 39 of 64 consecutive patients who underwent endorectal 3-T MRI prior to radical prostatectomy, prostate specimens were analyzed as whole-mount step sections. Apparent diffusion coefficient (ADC), normalized ADC (nADC: tumor/healthy tissue), choline/citrate (CC), and (choline + creatine)/citrate (CCC) ratios were correlated with Gleason scores (GS) from histopathological results. The power to discriminate low (GS ≤ 6) from higher-risk (GS ≥ 7) tumors was assessed with receiver operating characteristics (area under the curve [AUC]). Resulting threshold values were used by a blinded reader to distinguish between aggressive and indolent tumors.

RESULTS

Ninety lesions (1 × GS = 5, 41 × GS = 6, 36 × GS = 7, 12 × GS = 8) were considered. nADC (AUC = 0.90) showed a higher discriminatory power than ADC (AUC = 0.79). AUC for CC and CCC were 0.73 and 0.82, respectively. Using either nADC < 0.46 or CCC > 1.3, as well as both criteria for aggressive PCa, the reader correctly identified aggressive and indolent tumors in 31 (79%), 28 (72%), and 33 of 39 patients (85%), respectively. Predictions of tumor aggressiveness from TRUS-guided biopsies were correct in 27 of 36 patients (75%).

CONCLUSION

The combination of a highly sensitive normalized ADC with a highly specific CCC was found to be well suited to prospectively estimate PCa aggressiveness with a similar diagnostic accuracy as biopsy results.

Robot-assisted technique for boari flap ureteral reimplantation: is robot assistance beneficial?

BACKGROUND AND PURPOSE

Ureteral reconstructive surgery necessitates adequate exposure of the ureteral lesion and results in large abdominal incisions. Robot assistance allows the performance of complex ureteral reconstructive surgery through small incisions. The current series includes only cases of Boari flaps performed by robot assistance and attempts to describe in detail the technique, review the literature, as well as to expand the experience in the current literature.

PATIENTS AND METHODS

Eight patients underwent ureteral reimplantation by Boari flap technique. The indications for the performance of the procedure included ureteral stricture from iatrogenic injury in three patients, recurrent ureteral stricture after multiple endoscopic stone management procedures in one patient, ureteral stricture from previous malignant disease in the pelvis or abdomen in three patients, and ureteral stricture due to trauma in one patient. Five cases were located in the left side and three cases in the right side. A variety of parameters were recorded in a prospective database including the time for robot docking and total operative time as well as catheterization and drainage time. The follow-up of the patients included the performance of renal ultrasonography 4 weeks, 3, 6, and 12 months after the procedure.

RESULTS

Mean age of the patients was 50.8 (range 39-62) years and mean body mass index was 26.2 (range 23.22-29.29) kg/m(2). Operative time ranged 115 and 240 (mean 171.9) minutes. Mean blood loss was 161.3 (50-250) mL. Conversion to open surgery did not take place in the current series. No intraoperative complications were observed. Postoperative complications included one case of prolonged anastomotic leakage.

CONCLUSION

The robot-assisted approach is efficient in the performance of ureteral reimplantation with Boari flap. Low blood loss, short catheterization time, low complication rate, and excellent reconstructive outcome are associated with the approach. Robot assistance seems to be beneficial for ureteral reconstructive surgery.

Feasibility of minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen: feasibility and 1-year outcomes

OBJECTIVES

Urologists are cautious to offer minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen (and therefore anticipated to have locally advanced or metastatic disease) because of concerns regarding lack of complete cure after minimally invasive radical prostatectomy and of worsening of continence if adjuvant radiotherapy is used.

METHODS

A retrospective review of our institutional database was carried out to identify patients with PSA ≥20 ng/mL who underwent minimally invasive radical prostatectomy between January 2002 and October 2010. Intraoperative, pathological, functional and short-term oncological outcomes were assessed.

RESULTS

Overall, 233 patients met study criteria and were included in the analysis. The median prostate-specific antigen and prostate size were 28.5 ng/mL and 47 mL, respectively. Intraoperative complications were the following: rectal injury (0.86%) and blood transfusion (1.7%). Early postoperative complications included prolonged (>6 days) catheterization (9.4%), hematoma (4.7%), deep venous thrombosis (0.86%) and lymphocele (5.1%). Late postoperative complications included cerebrovascular accident (0.4%) and anastomotic stricture (0.8%). Pathology revealed poorly differentiated cancer in 48.9%, pT3/pT4 disease in 55.8%, positive margins in 28.3% and lymph node disease in 20.2% of the cases. Adverse pathological findings were more frequent in patients with prostate-specific antigen >40 ng/mL and (or) in those with locally advanced disease (pT3/pT4). In 62.2% of the cases, adjuvant radiotherapy was used. At 1-year follow up, 80% of patients did not show evidence of biochemical recurrence and 98.8% of them had good recovery of continence.

CONCLUSION

Minimally invasive radical prostatectomy might represent a reasonable option in prostate cancer patients with high prostate-specific antigen as a part of a multimodality treatment approach.

LESS nephrectomy: technique and outcomes

Laparoendoscopic single-site surgery (LESS) represents the next step of laparoscopic surgery and a major advancement towards scarless surgery. LESS radical nephrectomy is an evolving technique based on technological advancement of laparoscopic instruments as well as the refinement of existing techniques.The current report describes LESS nephrectomy technique, presents the experience with the technique in a series of 42 patients and reviews current literature in the field of LESS nephrectomy.

Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE): technique and outcome

Endoscopic extraperitoneal radical prostatectomy (EERPE) is a well-established and standardized technique for treating patients with localized prostate cancer. Nevertheless, the procedure is continuously being refined with the expansion of anatomical knowledge. The development of a nerve-sparing approach and improvements in currently used equipment are expected to yield better results in cosmesis and convalescence without sacrificing the procedure's established benefits in terms of potency, continence and oncological management. In this study, the technique and its evolution are presented in detail, along with an analysis of its clinical efficacy. We also consult the literature to compare EERPE to transperitoneal laparoscopic radical prostatectomy, and we also discuss new technical advancements regarding the use of robotic assistance during EERPE.

Laparoscopic radical and partial nephrectomy: technical issues and outcome

The laparoscopic approach has been established as a treatment modality for the performance of radical nephrectomy during the recent years, while laparoscopic partial nephrectomy represents an alternative under investigation in several centers of laparoscopic excellence around the world. Significant advantages of laparoscopic surgery when compared to the classical open approach have extensively documented for over 2 decades. Nevertheless, laparoscopy is an evolving surgical field, which is characterized by the rapid adaptation of technical innovations. Laparoscopic renal surgery includes approaches for radical and partial nephrectomy with oncological outcome similar to open surgery and decreased postoperative morbidity and therefore can be considered for the same indications as open surgery. Several issues regarding the technical feasibility and refinement as well as the oncological efficacy of these procedures are presented.

Clinical outcomes of laparo-endoscopic single-site surgery radical nephrectomy

INTRODUCTION

The conventional laparoscopic surgery is now paving way to the new technologies including robotic and laparoscopic single-site surgery (LESS). We present our updated experience on LESS radical nephrectomy (LESS-RN).

PATIENTS AND METHODS

The data from patients undergoing LESS-RN in our two institutions were reviewed along with various clinical and pathological parameters.

RESULTS

Between 2008 and 2011, 42 LESS-RN were performed (right = 22, left = 20) with mean (range) age and BMI of 63.7 (33-86) years and 25.1 (18-38.6) kg/m(2), respectively. In addition to the instruments in the single port, one extra 3-mm needlescopic instrument was required in 19 patients (right = 17, left = 2). In three patients, two additional 5-mm trocars and instruments were required. None required open conversion. The recorded adverse events include one bowel injury (intraoperative closure without the need for stoma), one postoperative bleeding requiring blood transfusion, one prolonged ileus, and one deep venous thrombosis. The resected specimens revealed pT1a (n = 3), pT1b (n = 33), pT2a (n = 4), and pT3b (n = 2) tumors. The finding of pT3b was incidental rather than planned procedure. None of the patients had positive margins.

CONCLUSION

LESS-RN has proven to be feasible and safe. Beyond cosmesis, further advantages of this approach need to be addressed by randomized trials.

Off-axis quantitative phase imaging processing using CUDA: toward real-time applications

We demonstrate real time off-axis Quantitative Phase Imaging (QPI) using a phase reconstruction algorithm based on NVIDIA's CUDA programming model. The phase unwrapping component is based on Goldstein's algorithm. By mapping the process of extracting phase information and unwrapping to GPU, we are able to speed up the whole procedure by more than 18.8× with respect to CPU processing and ultimately achieve video rate for mega-pixel images. Our CUDA implementation also supports processing of multiple images simultaneously. This enables our imaging system to support high speed, high throughput, and real-time image acquisition and visualization.

Cell imaging beyond the diffraction limit using sparse deconvolution spatial light interference microscopy

We present an imaging method, dSLIM, that combines a novel deconvolution algorithm with spatial light interference microscopy (SLIM), to achieve 2.3x resolution enhancement with respect to the diffraction limit. By exploiting the sparsity of the phase images, which is prominent in many biological imaging applications, and modeling of the image formation via complex fields, the very fine structures can be recovered which were blurred by the optics. With experiments on SLIM images, we demonstrate that significant improvements in spatial resolution can be obtained by the proposed approach. Moreover, the resolution improvement leads to higher accuracy in monitoring dynamic activity over time. Experiments with primary brain cells, i.e. neurons and glial cells, reveal new subdiffraction structures and motions. This new information can be used for studying vesicle transport in neurons, which may shed light on dynamic cell functioning. Finally, the method is flexible to incorporate a wide range of image models for different applications and can be utilized for all imaging modalities acquiring complex field images.

Laparoendoscopic single-site extraperitoneal inguinal hernia repair: initial experience in 10 patients

BACKGROUND AND PURPOSE

Recent technical advances and a trend toward laparoscopic single incision surgery have led us to explore the feasibility of laparoendoscopic single-site (LESS) hernia repair.

PATIENTS AND METHODS

We present our technique and initial experience with LESS extraperitoneal inguinal hernia repair in 10 consecutive men with unilateral inguinal hernias. Age range was 43.7 (28-64) years. Mean body mass index was 28 (range 24-30). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional totally extraperitoneal laparoscopic hernia repair as well as experienced in LESS. A literature review of current single-port inguinal hernia repair data is also presented.

RESULTS

The mean operative time was 53 minutes (range 45-65  min). The average length of skin incision was 2.8  cm (range 2.3-3.2  cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. The results of the current series compare favorably with those found in a literature review.

CONCLUSION

LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and if possible blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.

Prostatic biopsy undergrading: the feasibility of secondary laparoscopic pelvic lymphadenectomy

OBJECTIVES

Prostate biopsy grade is a key factor when deciding whether to perform pelvic lymph node dissection (PLND) at laparoscopic radical prostatectomy. In common with many laparoscopic radical prostatectomy centers, we perform PLND in patients found to have intermediate and high-risk prostate cancer based upon preoperative PSA, prostate biopsy and imaging. We assessed the feasibility of performing a secondary laparoscopic PLND 6 weeks postoperatively in the presence of postoperative upgrading in patients who did not have PLND.

METHODS

A prospective study recording the pathological results and operative outcomes prospectively over a 10-month period during which 24 patients underwent a secondary PLND. All patients had a preoperative PSA level <10 ng/ml and biopsy Gleason score of ≤6 (3 + 3) and the prostatectomy specimen was subsequently found to have a Gleason score of ≥7 (4 + 3) or increased stage.

RESULTS

During the 10-month period, 377 prostatectomies were carried out in our department in which 54 (18.3%) had an upgrading in the prostatectomy specimen. 24 patients (mean age 60 and mean PSA 6.7 ng/ml) agreed to a secondary PLND. No lymph nodes metastases were observed. One patient who was sexually potent following a nerve-sparing prostatectomy was impotent after the secondary PLND.

CONCLUSIONS

Upgrading of prostate Gleason score is seen in up to a third of cases in many large published series that is reflected in our experience. A laparoscopic secondary lymphadenectomy is feasible with low morbidity and yields valuable pathological clinical staging for subsequent surveillance and therapy for these high-risk patients.

Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting

INTRODUCTION

Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling.

MATERIALS AND METHODS

Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded.

RESULTS

Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port.

DISCUSSION

Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

Clinical Appliance of Laparo-Endoscopic Single-Site Surgery (LESS) in Urology

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.

Endoscopic extraperitoneal radical prostatectomy after previous transurethral resection of prostate: oncologic and functional outcomes of 100 cases

OBJECTIVES

To study radical prostatectomy that has been reported to be more challenging and associated with complications in patients with history of transurethral resection of prostate (TURP).

METHODS

In our series, 100 of 2300 patients had undergone endoscopic extraperitoneal radical prostatectomy (EERPE) after previous TURP. All patients included in the study had at least 1-year follow-up. Patient demographics, mean blood loss, mean catheterization time, complications, functional and oncologic outcome were reviewed.

RESULTS

In all, 100 patients underwent EERPE and 26 of these patients were treated by nerve-sparing EERPE. Lymphadenectomy was performed in 45 patients. Operative time and mean blood loss were similar to previous EERPE series. The transfusion rate and mean time of catheterization were slightly higher than general EERPE population. Positive surgical margin rates were 7% for pT2 and 36% for pT3/4. At 12-month follow-up, 94% of the patients did not experience prostate-specific antigen level>or=0.1 ng/mL. The overall complication rate was 14%. At 12 months, 93% of patients were continent, 4% used 1-2 pads/day and 3% needed >2 pads/day. The potency rates for the 26 patients who underwent nerve-sparing EERPE were 52.6% and 66.7% at 6 and 12 months, respectively.

CONCLUSIONS

Patients who had previously undergone TURP should be considered for radical treatment with EERPE. The procedure is safe even though technically more demanding. Perioperative, functional, and short-term oncologic outcome is promising and directly comparable to existing EERPE experience. Potency results were lower in comparison with existing EERPE series.

Number of women needed in a prospective trial to prove potential cardiovascular benefit of hormone replacement therapy

INTRODUCTION

Hormonal replacement therapy (HRT) may be beneficial for the cardiovascular system if hormones are given shortly after the onset of menopause. So far, no randomized trial has provided conclusive results.

MATERIALS AND METHODS

Based on Belgian population data, we calculated the number of women that should be included in a prospective double-blinded study to prove a potential cardiovascular benefit of HRT. Sample size calculations were based on the extrapolation of empirical observations made in three large databases from epidemiological studies carried out in Belgium during the past 20 years.

RESULTS

The 10-year mortality varies with the age at which women are included in the observation. In the normal Belgian female population, the cardiovascular mortality risk is 0.85% and 1.58% for women aged 50-54 and 55-59 years, respectively. To prove that HRT induces a decrease of 10-year mortality of 30% in a normal population of 50-54-year-old women, 34 630 subjects would have to be included; for reductions of 20% and 10%, the numbers would be, respectively, 82 468 and 348 056. To prove a significant decrease in 10-year mortality starting with a normal population with an average age of 55-59 years, the numbers needed for hypothetical reductions of 30%, 20% and 10% would be, respectively, 18 514, 44 072 and 185 936.

CONCLUSION

If cardiovascular mortality is the study end-point, it is obvious that such a study will be a gigantic task. Taking cardiovascular morbidity as the end-point, such a study would be feasible.

Prevention and management of perioperative complications in laparoscopic and endoscopic radical prostatectomy

INTRODUCTION

Laparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide.

RESULTS

The complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events.

CONCLUSION

Prevention and management of complications requires high surgical expertise and adequate standardization of the technique.

MATERIALS AND METHODS

We herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.