Total Anatomical Reconstruction during Robot-assisted Radical Prostatectomy: Implications on Early Recovery of Urinary Continence

Background: The introduction of robotics revolutionized prostate cancer surgery because the magnified three-dimensional vision system and wristed instruments allow microsurgery to be performed. The advantages of robotic surgery could lead to improved continence outcomes in terms of early recovery compared with the traditional surgical methods. Objective: To describe the total anatomical reconstruction (TAR) technique during robot-assisted radical prostatectomy (RARP). Primary endpoint: evaluation of the continence rate at different time points. Secondary endpoint: evaluation of urine leakage and anastomosis stenosis rates related to the technique. Design, setting, and participants: June, 2013 to November, 2014; prospective consecutive series of patients with localized prostate cancer (cT1-3, cN0, cM0). Surgical procedure: RARP with TAR was performed in all cases. Lymph node dissection was performed if the risk of lymph nodal metastasis was over 5%, according to the Briganti updated nomogram. Measurements: Preoperative, intraoperative, postoperative, and pathological variables were analyzed. Enrolled patients were arbitrarily divided into three groups according to a time criterion. The relationships between the learning curve and the trend of the above-mentioned variables were analyzed using LOESS analysis. Continence was rigorously analyzed preoperatively and at 24h, 1 wk, 4 wk, 12 wk, and 24 wk after catheter removal. Results and limitations: In total, 252 patients were analyzed. The continence rates immediately after catheter removal and at 1 wk, 4 wk, 12 wk, and 24 wk after RARP were 71.8%, 77.8%, 89.3%, 94.4%, and 98.0%, respectively. Multivariate analysis revealed that the nerve sparing technique, D'Amico risk groups, lymph node dissection, and prostate volume were involved in the early recovery of urinary continence. One ileal perforation requiring reoperation was recorded. The transfusion rate was 0.8%. Thirty-one (12.3%) postoperative complications were recorded up to 6 mo after surgery. Among these, eight acute urinary retentions (3.2%) and three urine leakages (1.2%) were recorded. There was a lack of randomization and comparison with other techniques. Both anatomical dissection of the prostatic apex and TAR were used. The results may not be generalized to low-volume centers. Conclusions: The TAR technique showed promising results in the early recovery of urinary continence, as well as watertight anastomosis and a low rate of urine leakage. The oncologic results were not affected. Comparative studies are needed to support the quality of reported results

Prescription appropriateness of anti-diabetes drugs in elderly patients hospitalized in a clinical setting: evidence from the REPOSI Register

Diabetes is an increasing global health burden with the highest prevalence (24.0%) observed in elderly people. Older diabetic adults have a greater risk of hospitalization and several geriatric syndromes than older nondiabetic adults. For these conditions, special care is required in prescribing therapies including anti- diabetes drugs. Aim of this study was to evaluate the appropriateness and the adherence to safety recommendations in the prescriptions of glucose-lowering drugs in hospitalized elderly patients with diabetes. Data for this cross-sectional study were obtained from the REgistro POliterapie-Società Italiana Medicina Interna (REPOSI) that collected clinical information on patients aged ≥ 65 years acutely admitted to Italian internal medicine and geriatric non-intensive care units (ICU) from 2010 up to 2019. Prescription appropriateness was assessed according to the 2019 AGS Beers Criteria and anti-diabetes drug data sheets.Among 5349 patients, 1624 (30.3%) had diagnosis of type 2 diabetes. At admission, 37.7% of diabetic patients received treatment with metformin, 37.3% insulin therapy, 16.4% sulfonylureas, and 11.4% glinides. Surprisingly, only 3.1% of diabetic patients were treated with new classes of anti- diabetes drugs. According to prescription criteria, at admission 15.4% of patients treated with metformin and 2.6% with sulfonylureas received inappropriately these treatments. At discharge, the inappropriateness of metformin therapy decreased (10.2%, P < 0.0001). According to Beers criteria, the inappropriate prescriptions of sulfonylureas raised to 29% both at admission and at discharge. This study shows a poor adherence to current guidelines on diabetes management in hospitalized elderly people with a high prevalence of inappropriate use of sulfonylureas according to the Beers criteria

Clampless laparoscopic partial nephrectomy: A step towards a harmless nephron-sparing surgery?

PURPOSE: To evaluate the results of our technique of clampless laparoscopic partial nephrectomy (LPN) and its impact as an emerging treatment for small renal masses (SMRs). MATERIALS AND METHODS: We reviewed our prospectively maintained database: data of 117 patients who consecutively underwent LPN at our Institution from January 2009 to December 2011 were studied. Patients were divided into 2 Groups based on operative technique: Group A: clampless-LPN (cl-LPN); Group B: conventional LPN (clamping of renal artery). Demographic and peri-operative data, complications, pre- and post-operative serum creatinine and estimated glomerular filtration rate (eGFR) were registered and compared by Student&#8217;s t- and Chi-square-tests (p-values < 0.05 considered statistically significant). RESULTS: 41 patients were in Group A and 76 in Group B. Groups were comparable in terms of preoperative data except for tumour&#8217;s size (2.35 ± 1.10 vs. 3.19 ± 1.57, Group A vs. B, respectively, p = 0.0029). Concerning perioperative data, warm ischemia time (WIT) was 0 min. in all Group A cases; mean WIT in Group B was 20.90 ± 9.27 min. One case (2.4%) in Group A (central tumour) was converted to conventional LPN. Mean eGFR postoperative decrease was higher in Group B (0.17 ± 9.30 vs. 4.38 ± 11.37 mL/min., A vs B, respectively, p = 0.0445). CONCLUSIONS: Notwithstanding the limits of the study, our results suggest that cl-LPN is a safe and effective technique, which allows surgeon to surgically treat SRMs even in case of complex location, without injuring kidney by ischemia

Percutaneously Assisted "two-Ports" Transperitoneal Radical Nephrectomy: Initial Series

Looking for a virtually "scarless" surgery mini-laparoscopy (ML) could be a viable alternative to conventional laparoscopy. ML is a reproducible technique and allows for the preservation of the triangulation concept, the cornerstone of laparoscopic surgery. Drawback of ML could be the poor performance of miniaturized instruments that could affect the confidence of the surgeon and limit the indications. The recent availability of a novel mini-laparoscopic platform in our center expanded the indications of ML to radical nephrectomy even in cases of large renal tumors in kidneys with abundant perirenal fat. The platform is composed by mini-instruments with the peculiarity of a 2.9-mm shaft that is mounted on a handle and a jaw that are comparable in size and performance to those of conventional instruments, increasing the ergonomy and the confidence perceived by the surgeon. Allowing for inclusion criteria, nine consecutive patients were enrolled in our prospective study and underwent percutaneously assisted "two-ports" radical nephrectomy. Preliminary data showed that the novel platform allowed us to perform a safe and effective procedure with acceptable perioperative outcomes and apparent improvements in cosmesis. Larger sample size and comparative studies are needed to confirm these findings

Mitochondrial Transplantation in Mitochondrial Medicine: Current Challenges and Future Perspectives

Mitochondrial diseases (MDs) are inherited genetic conditions characterized by pathogenic mutations in nuclear DNA (nDNA) or mitochondrial DNA (mtDNA). Current therapies are still far from being fully effective and from covering the broad spectrum of mutations in mtDNA. For example, unlike heteroplasmic conditions, MDs caused by homoplasmic mtDNA mutations do not yet benefit from advances in molecular approaches. An attractive method of providing dysfunctional cells and/or tissues with healthy mitochondria is mitochondrial transplantation. In this review, we discuss what is known about intercellular transfer of mitochondria and the methods used to transfer mitochondria both in vitro and in vivo, and we provide an outlook on future therapeutic applications. Overall, the transfer of healthy mitochondria containing wild-type mtDNA copies could induce a heteroplasmic shift even when homoplasmic mtDNA variants are present, with the aim of attenuating or preventing the progression of pathological clinical phenotypes. In summary, mitochondrial transplantation is a challenging but potentially ground-breaking option for the treatment of various mitochondrial pathologies, although several questions remain to be addressed before its application in mitochondrial medicine

Mitochondrial Transplantation in Mitochondrial Medicine: Current Challenges and Future Perspectives

Mitochondrial diseases (MDs) are inherited genetic conditions characterized by pathogenic mutations in nuclear DNA (nDNA) or mitochondrial DNA (mtDNA). Current therapies are still far from being fully effective and from covering the broad spectrum of mutations in mtDNA. For example, unlike heteroplasmic conditions, MDs caused by homoplasmic mtDNA mutations do not yet benefit from advances in molecular approaches. An attractive method of providing dysfunctional cells and/or tissues with healthy mitochondria is mitochondrial transplantation. In this review, we discuss what is known about intercellular transfer of mitochondria and the methods used to transfer mitochondria both in vitro and in vivo, and we provide an outlook on future therapeutic applications. Overall, the transfer of healthy mitochondria containing wild-type mtDNA copies could induce a heteroplasmic shift even when homoplasmic mtDNA variants are present, with the aim of attenuating or preventing the progression of pathological clinical phenotypes. In summary, mitochondrial transplantation is a challenging but potentially ground-breaking option for the treatment of various mitochondrial pathologies, although several questions remain to be addressed before its application in mitochondrial medicine