Blunt apical dissection during anatomic radical retropubic prostatectomy

<p>Abstract</p> <p>Background</p> <p>Meticulous apical dissection during a radical prostatectomy is imperative to achieve desirable pathologic and quality of life outcomes.</p> <p>Findings</p> <p>We describe a novel technique using careful blunt dissection to better delineate the apex of the prostate, providing a simple means to potentially lessen positive surgical margins at the apex and promote better continence and erectile function in men undergoing an anatomic radical prostatectomy.</p> <p>Median operative time and blood loss were 190 minutes and 675 mL, respectively. Only 10 percent of the patients with positive surgical margins were found to have apical positive surgical margins. Ninety-three percent of patients reported no urinary leakage.</p> <p>Conclusion</p> <p>We believe our technique of isolating the DVC with blunt dissection and then ligating and transecting the DVC to be feasible approach that requires larger studies to truly confirm its utility.</p

Introducing an efficient model for the prediction of placenta accreta spectrum using the MCP regression approach based on sonography indexes: how efficient is sonography in diagnosing accreta?

Background For the first time, we aimed to introduce a model for prediction of placenta accreta spectrum (PAS), using existing sonography indices. Methods Women with a history of Cesarean sections were included. Participants were categorized "high risk" for PAS if the placenta was previa or low-lying. Sonography indices including abnormal placental lacuna, loss of clear zone, bladder wall interruption, myometrial thinning, placental bulging, exophytic mass, utero-vesical hypervascularity, subplacental hypervascularity, existence of bridging vessels, and lacunar flow, were registered. To investigate simultaneous effects of 15 variables on PAS, Minimax Concave Penalty (MCP) was used. Results Among 259 participants, 74 (28.5%) were high risk and 43 individuals had PASs. All sonography indices were higher among patient with PAS (p < 0.001) in the high risk group. Our model showed that utero-vesical hypervascularity, bladder interruption and new lacunae have significant contribution in PAS. Optimal cut off point was p = 0.51 in ROC analysis. Probability of PAS for women with lacunae was between 96 and 100% and probability of PAS for women without lacunae was between 0 to 7%, therefore accuracy of the proposed model was equal to 100%. Conclusions Using the introduced model based on three factors of abnormal lacuna structures (grades 2 and 3), bladder wall interruption and utero-vesical vascularity, 100% of all cases of PASs are diagnosable. If supported by future studies our model eliminates the need for other imaging assessments for diagnosis of invasive placentation among high risk women Keywords:Morbidly adherent placenta; Placenta accreta spectrum; Ultrasonography; Accreta; Diagnosi

Positive effect of low dose vitamin D supplementation on growth of fetal bones: A randomized prospective study

The effect of vitamin D supplementation on growth of fetal bones during pregnancy is unclear. The aim of this study was to assess the effect of low dose vitamin D supplementation during pregnancy on bony anthropometric aspects of the fetus. In this prospective randomized trial, 140 patients were divided into two equally matched groups according to age, 25(OH)D level, exercise, and dietary intake. Then 1000 IU per day vitamin D supplement was given to the intervention group while the control group received placebo. Then crown-rump length (CRL) and femur length (FL) during the first trimester and humerus and femur lengths as well as their proximal metaphyseal diameter (PMD), midshaft diameter (MSD) and distal metaphyseal diameter (DMD) in the second and third trimester were measured using ultrasonography technique. Finally, no significant difference was observed for CRL (p = 0.93). Although FL was not statistically significant in the first trimester (p = 0.54), its measurement in the intervention group and the control group in the second (28.87 ± 2.14 vs. 26.89 ± 2.08; p ≤0.001) and the third (65.31 ± 2.17 vs. 62.85 ± 1.94; p ≤0.001) trimesters was significantly different. Femoral PMD, MSD, and DMD measurement increased more in the intervention group in comparison with the control group with P values <0.05. HL measurement in the intervention group and the control group in the second (28.62 ± 1.94 vs. 27.23 ± 2.08; p ≤0.001) and the third (61.29 ± 2.84 vs. 59.85 ± 1.79; p ≤0.001) trimesters revealed significant differences. Humeral PMD, MSD, and DMD measurement increased in the intervention group in comparison with the control group with P values <0.001 for all. It is suggested to prescribe low dose vitamin D (1000 IU per day) from early pregnancy with possible increment in length and diameter of femur and humerus bones of the fetus

Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy

CONTEXT: Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly performed. OBJECTIVE: To report on a systematic literature review and cumulative analysis of pathologic, oncologic, and functional outcomes of RARC in comparison with ORC and LRC. EVIDENCE ACQUISITION: Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. A cumulative analysis was conducted. EVIDENCE SYNTHESIS: The searches retrieved 105 papers, 87 of which reported on pathologic, oncologic, or functional outcomes. Most series were retrospective and had small case numbers, short follow-up, and potential patient selection bias. The lymph node yield during lymph node dissection was 19 (range: 3-55), with half of the series following an extended template (yield range: 11-55). The lymph node-positive rate was 22%. The performance of lymphadenectomy was correlated with surgeon and institutional volume. Cumulative analyses showed no significant difference in lymph node yield between RARC and ORC. Positive surgical margin (PSM) rates were 5.6% (1-1.5% in pT2 disease and 0-25% in pT3 and higher disease). PSM rates did not appear to decrease with sequential case numbers. Cumulative analyses showed no significant difference in rates of surgical margins between RARC and ORC or RARC and LRC. Neoadjuvant chemotherapy use ranged from 0% to 31%, with adjuvant chemotherapy used in 4-29% of patients. Only six series reported a mean follow-up of >36 mo. Three-year disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) rates were 67-76%, 68-83%, and 61-80%, respectively. The 5-yr DFS, CSS, and OS rates were 53-74%, 66-80%, and 39-66%, respectively. Similar to ORC, disease of higher pathologic stage or evidence of lymph node involvement was associated with worse survival. Very limited data were available with respect to functional outcomes. The 12-mo continence rates with continent diversion were 83-100% in men for daytime continence and 66-76% for nighttime continence. In one series, potency was recovered in 63% of patients who were evaluable at 12 mo. CONCLUSIONS: Oncologic and functional data from RARC remain immature, and longer-term prospective studies are needed. Cumulative analyses demonstrated that lymph node yields and PSM rates were similar between RARC and ORC. Conclusive long-term survival outcomes for RARC were limited, although oncologic outcomes up to 5 yr were similar to those reported for ORC. PATIENT SUMMARY: Although open radical cystectomy (RC) is still regarded as the standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RCs are becoming more popular. Templates of lymph node dissection, lymph node yields, and positive surgical margin rates are acceptable with robot-assisted RC. Although definitive comparisons with open RC with respect to oncologic or functional outcomes are lacking, early results appear comparable

Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy

CONTEXT: Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) have gained popularity. OBJECTIVE: To report a systematic literature review and cumulative analysis of perioperative outcomes and complications of RARC in comparison with ORC and LRC. EVIDENCE ACQUISITION: Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. Cumulative analysis was conducted. EVIDENCE SYNTHESIS: The searches retrieved 105 papers. According to the different diversion type, overall mean operative time ranged from 360 to 420 min. Similarly, mean blood loss ranged from 260 to 480 ml. Mean in-hospital stay was about 9 d for all diversion types, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-d complication rates were 59% (high-grade complication: 15%). In series reporting RARC with intracorporeal continent diversion, the overall 30-d complication rate was 45.7% (high-grade complication: 28%). Reported mortality rates were ≤3% for all diversion types. Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (all p values <0.003). Moreover, 90-d complication rates of any-grade and 90-d grade 3 complication rates were lower for RARC (all p values <0.04), whereas high-grade complication and mortality rates were similar. CONCLUSIONS: RARC can be performed safely with acceptable perioperative outcome, although complications are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas RARC may provide some advantages in terms of blood loss and transfusion rates and, more limitedly, for postoperative complication rates over ORC and LRC. PATIENT SUMMARY: Although open radical cystectomy (RC) is still regarded as a standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RC are becoming more popular. Robotic RC can be safely performed with acceptably low risk of blood loss, transfusion, and intraoperative complications; however, as for open RC, the risk of postoperative complications is high, including a substantial risk of major complication and reoperation

Comparison of the Effects of Maternal Supportive Care and Acupressure (BL32 Acupoint) on Pregnant Women’s Pain Intensity and Delivery Outcome

Delivery is considered as one of the most painful experiences of women’s life. The present study aimed to compare the effects of supportive care and acupressure on the pregnant women’s pain intensity and delivery outcome. In this experimental study, 150 pregnant women were randomly divided into supportive care, acupressure, and control groups. The intensity of pain was measured using Visual Analogue Scale (VAS). The supportive care group received both physical and emotional cares. In the acupressure group, on the other hand, BL32 acupoint was pressed during the contractions. Then, the data were analyzed using descriptive and inferential statistics. The results revealed significant difference among the three groups regarding the intensity of pain after the intervention (P<0.001). Besides, the highest rate of natural vaginal delivery was observed in the supportive care group (94%) and the acupressure group (92%), while the highest rate of cesarean delivery was related to the control group (40%) and the difference was statistically significant (P<0.001). The results showed that maternal supportive care and acupressure during labor reduced the intensity of pain and improved the delivery outcomes. Therefore, these methods can be introduced to the medical team as effective strategies for decreasing delivery pain. This trial is registered with the Iranian Registry of Clinical Trial Code IRCT2014011011706N5