Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

En Bloc Thulium Laser Enucleation of the Prostate: A Step-by-Step Guide to Improve Enucleation Time and Efficiency for Endoscopic Enucleation of Prostatic Adenoma

OBJECTIVE: To present a reproducible step-by-step approach to en bloc thulium laser enucleation of the prostate (ThuLEP) for benign prostatic hyperplasia surgical treatment. Laser adenoma enucleation is nowadays a recognized surgical treatment for benign prostatic enlargement. Some variants to the classical 3-lobes laser technique have been proposed, in order to overcome the main concerns regarding the original procedure.1-4 After a vast experience with the 3-lobes ThuLEP, we developed our own en bloc enucleation technique. METHODS: The capsular plane is identified only once, at the level of the prostatic apex, at 5 o'clock; this plane is followed ascending towards the bladder neck, separating the left lobe from the prostatic capsule from 5 to 11 o'clock. The right and median lobes are then enucleated following the same plane clockwise and the 2 planes are joined anteriorly at 11 o'clock. Finally, enucleation is completed by incising the remaining mucosal flap from 10 to 2 o'clock. We have already proved the clear advantages provided by this technique compared to the "3-lobes" enucleation.5 RESULTS: Our single-center experience with this technique includes 140 procedures performed up to June 2018. Mean prostatic adenoma volume was 66.7 mL (range 20-220 \ub1 32.85 standard deviation [SD]). Mean total surgical time was 60.93 minutes (25-133 \ub1 23.6 SD); mean enucleation time was 18.3 minutes (8.2-36.53 \ub1 5.62 SD), mean enucleation time normalized per adenoma gram was 0.32 min/g (0.12-0.8 \ub1 0.15 SD) and mean energy needed for the enucleation normalized per adenoma gram was 1852.13 J/g (689-6129 \ub1 862.4 SD). Only 1 case of reintervention for clot evacuation (Clavien grade IIIb) was necessary. CONCLUSION: En bloc ThuLEP provides an anatomical approach for endoscopic enucleation of prostatic adenoma. We believe that this sequence optimizes efficiency and efficacy in a reproducible way

Laparoscopic access overview: Is there a safest entry method?

Background Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one. Methods Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers. Results The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%. Conclusion Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest

Atributos físico-químicos de um Latossolo do Cerrado brasileiro e sua relação com características dendrométricas do eucalipto Dendrometric parameters of eucalyptus and their relationship with physical-chemical characteristics of a Latosol in the Brazilian Cerrado

A resistência mecânica à penetração do solo exerce grande influência sobre o crescimento e desenvolvimento vegetal, uma vez que o crescimento das raízes e o rendimento das culturas variam de forma inversamente proporcional ao seu valor. Por outro lado, a matéria orgânica e o pH do solo também são atributos relevantes ao crescimento das plantas, pois estão diretamente ligados à disponibilidade de nutrientes do solo. No ano agrícola 2005/2006, na Fazenda Experimental de Ensino e Pesquisa da Faculdade de Engenharia/UNESP, município de Selvíria, MS (22 º 23 ' de latitude S; 51 º 27 ' de longitude W), em um cultivo de Eucalyptus camaldulensis, foram analisados: (a) características dendrométricas da planta: volume de madeira (VOL), perímetro à altura do peito (PAP) e altura (ALT); e (b) atributos do solo em profundidade: resistência mecânica à penetração (RP), umidade gravimétrica (UG), matéria orgânica (MO) e o pH, num Latossolo Vermelho distrófico do Cerrado brasileiro. O objetivo foi estudar as correlações lineares e espaciais entre essas variáveis, buscando determinar indicadores de qualidade do solo para o eucalipto. Dados do solo e da planta foram coletados em uma malha geoestatística com 122 pontos amostrais, numa área de 1,98 ha. Os atributos da planta apresentaram média e alta variabilidade dos dados, ao passo que os do solo mostraram variabilidade baixa, média e alta. Os atributos VOL, PAP, ALT, RP, UG, MO e o pH não variaram aleatoriamente, seguindo padrões espaciais bem definidos, com alcances entre 17 e 169 m. As correlações lineares simples entre as características da planta e os atributos do solo foram baixas, porém significativas entre os pares VOL vs RP1, VOL vs RP5, VOL vs MO2 e VOL vs pH1. Do ponto de vista espacial, ocorreu significativa variação inversa do VOL com a RP5 e o pH1. O pH do solo, amostrado de 0-0,15 m de profundidade, quando destinado à estimativa da produtividade de madeira do Eucalyptus camaldulensis, apresentou-se como potente indicador da qualidade do solo estudado de Selvíria.<br>Soil mechanical penetration resistance exerts a strong influence on plant development since the root growth as well as crop yield are inversely related to this variable. On the other hand, soil organic matter and pH are also relevant for plant development, for being directly linked to soil nutrient availability. In the 2005/2006 growing season, the following dendrometric parameters of Eucalyptus camaldulensis were analyzed: (a) wood volume (WV), (b) perimeter at breast height (PBH) and c) plant height (PH), and the soil attributes: a) mechanical penetration resistance (MP), b) gravimetric moisture (GR), (c) organic matters (OM) and (d) and pH in a Dystrophic Red Latosol of the Cerrado (savanna-like vegetation). The purpose was to study the linear and spatial correlations among these variables, and to obtain soil quality indices for eucalyptus. A geostatistical grid was installed to collect soil and plant data, with 122 sample points, in an area of 1.98 ha. The variability of the plant data was medium and high, while the variability of the soil data was low, medium and high. The attributes WV, PB, PH, MP, GR, OM, and pH did not change randomly. Rather, they followed well-defined spatial patterns, with ranges between 17 and 169 m. The simple linear correlations among the attributes (plant and soil) were low, however significant for the attribute pairs WV vs MP1, WV vs MP5, WV vs OM2 and WV vs pH1. From the spatial correlation viewpoint WV varied significantly, inversely proportional to MP5 and pH1. The soil pH, sampled from the 0-0.15 m layer (pH1), turned out to be the best quality indicator of the studied soil toward estimating eucalyptus wood yield

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy

The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy. Materials and Methods: A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes. Results: Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values &lt; 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values &lt; 0.05). Conclusion: In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions