Correção de fistula reto-uretral pela técnica de York-Mason

OBJECTIVE: Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. There is no consensus in the literature regarding the treatment of these fistulas. We present here our experiences treating recto-urethral fistulas. MATERIAL AND METHODS: We analyzed 8 cases of rectourethral fistula treated at our institution in the last seven years. Seven of the patients underwent repair of the fistula using the modified York-Mason procedure. RESULTS: The causes of the fistula were radical retropubic prostatectomy in five patients, perineal debridement of Fournier's gangrene in one, transvesical prostatectomy in one and transurethral resection of the prostate in the other patient. The most common clinical manifestation was fecaluria, present in 87.5% of the cases. The mean time elapsed between diagnosis and correction of the fistula was 29.6 (7-63) months. One spontaneous closure occurred after five months of delayed catheterization. Urinary and retrograde urethrocystography indicated the site of the fistula in 71.4% of the cases. No patient presented recurrence of the fistula after its correction with the modified York-Mason procedure. CONCLUSION: The performance of routine colostomy and cystostomy is unnecessary. The technique described by York-Mason permits easy access, reduces surgical and hospitalization times and presents low complication and morbidity rates when surgically correcting recto-urethral fistulas.OBJETIVO: As fístulas reto-uretrais são de acesso difícil e por vezes complexo, sendo seu fechamento espontâneo raro. Com o diagnóstico precoce e aumento do número de intervenções, principalmente a cirurgia por adenocarcinoma da próstata localizado, sua incidência apesar de rara vem crescendo. Nós demonstramos a nossa experiência dos casos de fístulas reto-uretrais entre 2000 a 2006 com uma serie de oito pacientes, sendo que sete realizaram correção da fístula pela Técnica de York Mason modificada. MATERIAL E MÉTODO: Nos retrospectivamente analisamos os prontuários de todos os casos de fístulas reto-uretrais tratados no nosso serviço no período de 2000 a 2006. Sete de oito pacientes realizaram reparo da fístula através do procedimento de York Mason modificado. RESULTADOS: Cinco pacientes tiveram a fístula como conseqüência da Prostatectomia Radical Retropúbica, sendo os outros três após debridamento devido a Fasceíte de Fournier, Prostatectomia Transvesical e Ressecção Transuretral da Próstata. A fecalúria foi o quadro clínico prevalente em 87,5% dos casos, o tempo médio entre o diagnóstico e a correção da fístula foi de 29,6 (7-63 meses) ocorreu um fechamento espontâneo após cinco meses de sondagem vesical de demora, a Uretrocistografia Retrograda e Miccional demonstrou a localização da fístula em 71,4%. Nenhum paciente apresentou recidiva da fístula após correção pela técnica de York Mason modificada. A colostomia foi realizada em 50% dos casos e não ocorreram casos de incontinência fecal ou estenose anal. CONCLUÇÃO: Após identificação de fístula reto-uretral, não é necessário à realização de colostomia e cistostomia de rotina. Sua correção pela técnica descrita por York Mason modificada nos propicia fácil acesso a sua localização, diminui o tempo cirúrgico e de internação, com baixos índices de complicações e morbidade

Survival of patients with prostate cancer and normal PSA levels treated by radical prostatectomy

INTRODUCTION: The unpredictability of prostate cancer has become a daily challenge for the urologist, with different strategies being required to manage these cases. In this study, we report on the perspectives for curing prostate cancer in males undergoing radical prostatectomy with Gleason score of 2-6 on prostate biopsy in relation to pre-operative PSA levels. MATERIALS AND METHODS: From 1991 - 2000, we selected 440 individuals whose pathological diagnosis revealed a Gleason score of 2-6 upon prostate biopsy and who subsequently underwent retro-pubic radical prostatectomy due to localized prostate cancer. The clinical stage identified in the group under study was T1c: 206 (46.8%); T2a: 122 (27.7%); T2b: 93 (21.1%); T2c: 17 (3.9%); T3a: 2 (0.5%). Following surgery, we constructed a biochemical recurrence-free survival curve according to pre-operative PSA levels between 0-4; 4.1-10; 10.1-20 and > 20 ng/mL, with a median follow-up of 5 years. RESULTS: Following radical prostatectomy, the pathological stage was confirmed as pT2a: 137 (31.1%); T2b: 118 (26.8%); T2c: 85 (19.3%); T3a: 67 (15.2%); T3b: 6 (1.4%); T3c: 22 (5%). The biochemical recurrence-free survival, according to PSA values between 0-4; 4.1-10; 10.1-20 and > 20 ng/mL, was 86.6%, 62.7%, 39.8% and 24.8% respectively. CONCLUSION: Better chances for curing low-grade prostate cancer occur in individuals with normal PSA for whom a biopsy is not usually recommended.Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM) Department of UrologyUNIFESP, EPM, Department of UrologySciEL

Clinical Study Long-Term Outcome after Laparoscopic Bowel Resections for Deep Infiltrating Endometriosis: A Single-Center Experience after 900 Cases

Background. Laparoscopic bowel resections for endometriosis are safe and effective but only short-term follow-up has been evaluated. In the present study long-term outcome in terms of intestinal and urinary function, fertility, chronic pain, and recurrence was assessed. Materials and Methods. From January 2002 to December 2010 nine hundred patients underwent laparoscopic bowel resection for endometriosis, and on 774 (86%) a questionnaire was administered. Patients were divided into 3 groups on the strength of the operation date. Postoperative diarrhea, constipation, rectal bleeding, tenesmus, dyschezia, dysuria, dyspareunia, fertility, and recurrence of disease were assessed. Results. The median follow-up was 54 months (range 1-120). All the evaluated symptoms significantly improved over time, with = 0.0001 for dyspareunia, constipation, and pelvic pain and = 0.004 for diarrhea. Nonsignificant improvement was reported for dysuria and rectal bleeding (with = 0.452 and = 0.097, resp.). Conclusions. The present results confirm that bowel resections for endometriosis are correlated with an acceptable complication rate even at longterm follow-up and that symptoms significantly improve over time, except for rectal bleeding and dysuria, the latter associated with a neurological damage

Extent of Surgery and Implications of Transection Margin Status after Resection of IPMNs

Appropriate surgical strategies for management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a matter of debate. Preoperative and intraoperative evaluation of malignant potential of IPMN and of patient’s comorbidities is of paramount importance to balance potential complications of surgery with tumors’ risk of being or becoming malignant; the decision about the extent of pancreatic resection and the eventual total pancreatectomy needs to be determined on individual basis. The analysis of frozen-section margin of pancreas during operation is mandatory. The goal should be the complete resection of IPMN reaching negative margin, although there is still no agreed definition of “negative margin.” Of note, the presence of deepithelization is often wrongly interpreted as absence of neoplasia. Management of resection margin status and stratification of surveillance of the remnant pancreas, based on characteristics of primary tumour, are of crucial importance in the management of IPMNs in order to decrease the risk of tumor recurrence after resection. Although risk of local and distant recurrence for invasive IPMNs is increased even in case of total pancreatectomy, also local recurrence after complete resection of noninvasive IPMNs is not negligible. Therefore, a long-term/life-time follow-up monitoring is of paramount importance to detect eventual recurrences

European' health care indicators and pancreatic cancer incidence and mortality: A mediation analysis of Eurostat data and Global Burden of Disease Study 2019.

AimTo highlight correlations existing between incidence and mortality of pancreatic cancer, and health care indicators in 36 European countries.MethodsThe Global Burden of Disease (GBD) and Eurostat databases were queried between 2004 and 2019. Incidence and mortality were age-standardized. From Eurostat, indicators regarding expenditure, hospital beds, medical technology, health personnel, physicians by medical specialty and unmet needs for medical examination were extracted. Correlations between GBD and Eurostat data were analysed through mediation analysis applying clustering for countries.ResultsIncidence increased by +0.6% per year (p = 0.001) and mortality by +0.3% (p = 0.001), being increasing for most of the European countries considered. Incidence and mortality were strongly positively correlated (p = 0.001). Higher current health expenditure, expenditure in inpatient curative care, the number of available beds, the number of computed tomography scan, magnetic resonance units, practising medical doctors were all related to higher incidence (p ConclusionsHealth care environment correlates with reported incidence and mortality of pancreatic cancer. This highlights both that ameliorated socio-economic societies suffer from higher incidence but lower mortality, as well as the epidemiological bias originating from countries' diagnostic ability

Colchicine treatment in amyotrophic lateral sclerosis: safety, biological and clinical effects in a randomized clinical trial

: In preclinical studies, the anti-inflammatory drug colchicine, which has never been tested in amyotrophic lateral sclerosis, enhanced the expression of autophagy factors and inhibited accumulation of transactive response DNA-binding protein 43 kDa, a known histopathological marker of amyotrophic lateral sclerosis. This multicentre, randomized, double-blind trial enrolled patients with probable or definite amyotrophic lateral sclerosis who experienced symptom onset within the past 18 months. Patients were randomly assigned in a 1:1:1 ratio to receive colchicine at a dose of 0.005 mg/kg/day, 0.01 mg/kg/day or placebo for a treatment period of 30 weeks. The number of positive responders, defined as patients with a decrease lesser than 4 points in the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised total score during the 30-week treatment period, was the primary outcome. Disease progression, survival, safety and quality of life at the end of treatment were the secondary clinical outcomes. Secondary biological outcomes included changes from baseline to treatment end of stress granule and autophagy responses, transactive response DNA-binding protein 43 kDa, neurofilament accumulation and extracellular vesicle secretion, between the colchicine and placebo groups. Fifty-four patients were randomized to receive colchicine (n = 18 for each colchicine arm) or placebo (n = 18). The number of positive responders did not differ between the placebo and colchicine groups: 2 out of 18 patients (11.1%) in the placebo group, 5 out of 18 patients (27.8%) in the colchicine 0.005 mg/kg/day group (odds ratio = 3.1, 97.5% confidence interval 0.4-37.2, P = 0.22) and 1 out of 18 patients (5.6%) in the colchicine 0.01 mg/kg/day group (odds ratio = 0.5, 97.5% confidence interval 0.01-10.2, P = 0.55). During treatment, a slower Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised decline was detected in patients receiving colchicine 0.005 mg/kg/day (mean difference = 0.53, 97.5% confidence interval 0.07-0.99, P = 0.011). Eight patients experienced adverse events in placebo arm (44.4%), three in colchicine 0.005 mg/kg/day (16.7%) and seven in colchicine 0.01 mg/kg/day arm (35.9%). The differences in adverse events were not statistically significant. In conclusion, colchicine treatment was safe for amyotrophic lateral sclerosis patients. Further studies are required to better understand mechanisms of action and clinical effects of colchicine in this condition

Knowledge and attitudes towards clinical trials among women with ovarian cancer: results of the ACTO study

Background Despite several initiatives by research groups, regulatory authorities, and scientific associations to engage citizens/patients in clinical research, there are still obstacles to participation. Among the main discouraging aspects are incomplete understanding of the concepts related to a clinical trial, and the scant, sometimes confused, explanations given. This observational, cross-sectional multicenter study investigated knowledge, attitudes and trust in clinical research. We conducted a survey among women with ovarian cancer at their first follow-up visit or first therapy session, treated in centers belonging to the Mario Negri Gynecologic Oncology (MaNGO) and Multicenter Italian Trials in Ovarian Cancer (MITO) groups. A questionnaire on knowledge, attitudes and experience was assembled ad hoc after a literature review and a validation process involving patients of the Alliance against Ovarian Cancer (ACTO). Results From 25 centers 348 questionnaire were collected; 73.5% of responders were 56 years or older, 54.8% had a high level of education, more than 80% had no experience of trial participation. Among participants 59% knew what clinical trials were and 71% what informed consent was. However, more than half did not know the meaning of the term randomization. More than half (56%) were in favor of participating in a clinical trial, but 35% were not certain. Almost all responders acknowledged the doctor's importance in decision-making. Patients' associations were recognized as having a powerful role in the design and planning of clinical trials. Conclusions This study helps depict the knowledge and attitudes of women with ovarian cancer in relation to clinical trials, suggesting measures aimed at improving trial "culture", literacy and compliance, and fresh ways of communication between doctors and patients

Quantum Computing for High-Energy Physics: State of the Art and Challenges. Summary of the QC4HEP Working Group

Quantum computers offer an intriguing path for a paradigmatic change of computing in the natural sciences and beyond, with the potential for achieving a so-called quantum advantage, namely a significant (in some cases exponential) speed-up of numerical simulations. The rapid development of hardware devices with various realizations of qubits enables the execution of small scale but representative applications on quantum computers. In particular, the high-energy physics community plays a pivotal role in accessing the power of quantum computing, since the field is a driving source for challenging computational problems. This concerns, on the theoretical side, the exploration of models which are very hard or even impossible to address with classical techniques and, on the experimental side, the enormous data challenge of newly emerging experiments, such as the upgrade of the Large Hadron Collider. In this roadmap paper, led by CERN, DESY and IBM, we provide the status of high-energy physics quantum computations and give examples for theoretical and experimental target benchmark applications, which can be addressed in the near future. Having the IBM 100 x 100 challenge in mind, where possible, we also provide resource estimates for the examples given using error mitigated quantum computing

The association of indwelling urinary catheter with delirium in hospitalized patients and nursing home residents: an explorative analysis from the "Delirium Day 2015"

Backround: Use of indwelling urinary catheter (IUC) in older adults has negative consequences, including delirium. Aim: This analysis, from the "Delirium Day 2015", a nationwide multicenter prevalence study, aim to evaluate the association of IUC with delirium in hospitalized and Nursing Homes (NHs) patients. Methods: Patients underwent a comprehensive geriatric assessment, including the presence of IUC; inclusion criteria were age > 65 years, being Italian speaker and providing informed consent; exclusion criteria were coma, aphasia, end-of-life status. Delirium was assessed using the 4AT test (score ≥ 4: possible delirium; scores 1-3: possible cognitive impairment). Results: Among 1867 hospitalized patients (mean age 82.0 ± 7.5 years, 58% female), 539 (28.9%) had IUC, 429 (22.9%) delirium and 675 (36.1%) cognitive impairment. IUC was significantly associated with cognitive impairment (OR 1.60, 95% CI 1.19-2.16) and delirium (2.45, 95% CI 1.73-3.47), this latter being significant also in the subset of patients without dementia (OR 2.28, 95% CI 1.52-3.43). Inattention and impaired alertness were also independently associated with IUC. Among 1454 NHs residents (mean age 84.4 ± 7.4 years, 70.% female), 63 (4.3%) had IUC, 535 (36.8%) a 4AT score ≥ 4, and 653 (44.9%) a 4AT score 1-3. The multivariate logistic regression analysis did not show a significant association between 4AT test or its specific items with IUC, neither in the subset of patients without dementia. Discussion: We confirmed a significant association between IUC and delirium in hospitalized patients but not in NHs residents. Conclusion: Environmental and clinical factors of acute setting might contribute to IUC-associated delirium occurrence

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys