Ioannis Heretis

Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: A preliminary case-controlled study

Introduction: Hemostasis is of utmost importance in urologic cancer surgery. The aim of this initial case-controlled study was to evaluate the use of an electrothermal biporal coagulator (Ligasure device) in major urologic procedures, including open radical prostatectomies and radical cystectomies. Materials and methods: Over the years 2001 to 2002, 58 patients patients aged 56–74 years (mean: 65 years) underwent open radical prostatectomies and open radical cystectomies performed by the same surgeon, employing either conventional ligation in the control group (radical prostatectomy, n = 15; radical cystectomy n = 9) or the Ligasure device in the study group (radical prostatectomy, n = 24; radical cystectomy n = 10) to ensure blood vessel patency. Effectiveness and postoperative outcomes were evaluated. Results: The 2 groups were similar regarding demographic and clinical variables. The mean operation time was significantly shorter in the Ligasure group compared with the control group for both the prostatectomy (125 minutes vs. 144 minutes, p < 0.001) and the cystectomy procedures (253 minutes vs. 281 minutes, p < 0.001). The mean intra-operation blood loss was significantly lower in the Ligasure group compared with the control group for both prostatectomy (569 ml vs. 685 ml, p = 0.04) and cystectomy procedures (637 ml vs. 744 ml, p = 0.02). Intraoperative blood transfusion was only required in 2 patients (1 radical prostatectomy, 1 radical cystectomy) in the Ligasure group and in 7 patients in the control group respectively (p = 0.01). There was no effect of surgical specimen size on operation time for both prostatectomy (r = -0.03, p = 0.8, n = 39) and cystectomy procedures (r = 0.02, p = 0.9, n = 19). There were no serious intra-operation or postoperative complications related to the use of the Ligasure device. Conclusions: Ligasure radical prostatectomy and radical cystectomy are safe, and significantly decrease both the operation time and the blood loss, when compared to the conventional ligation method.

Contrast-induced nephropathy: Basic concepts, pathophysiological implications and prevention strategies☆

&NA; Contrast‐induced nephropathy (CIN) is reversible acute renal failure observed following administration of iodinated contrast media (CM) during angiographic or other medical procedures such as urography. There are various mechanisms through which CM develop their nephrotoxic effects, including oxidative stress and apoptosis. CIN is a real‐life, albeit not very rare, entity. Exact pathophysiology remains obscure and no standard diagnostic criteria apply. The Acute Kidney Injury Network criteria was recently employed but its incidence/clinical significance warrants further clarification based on recent methodological advancements, because most published studies to date were contaminated by bias. The current study is a comprehensive review conducted to provide an overview of the basic concepts of CIN and summarize recent knowledge on its pathophysiology and the evidence supporting potential prevention strategies. CIN is expected to increase morbidity, hospital stay and mortality, while all patients scheduled to receive CM should undergo risk assessment for CIN and high‐risk patients may be considered candidates for prevention strategies. The value of using compounds with antioxidant properties other than sodium bicarbonate, remains controversial, warranting further clinical investigation.

Extracorporeal shock wave lithotripsy in the treatment of pediatric urolithiasis: a single institution experience

PURPOSE To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model. MATERIALS AND METHODS Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F--XP Dornier lithotripter was used from April 2003 to May 2006. RESULTS In the first group, 21/26 children (80.7%) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23%), brief hematuria (<24 h) resolved with increased fluid intake in 5 (19.2%), while slightly elevated body temperature (<38°C) occurred in 4 (15.3%). Four children (15.3%) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7%). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26%), brief hematuria (<24 h), resolved with increased fluid intake in 4 (21%) and slightly elevated body temperature (<38° C) monitored for 48 hours occurred in 6 (31.5%). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model. CONCLUSIONS Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

Does ivabradine exhibit a role in the reduction of bladder overactivity

Dear Editor, Ivabradine is a novel selective and specific inhibitor of the sinus node If current that induces heart rate reduction in a dose-dependent manner, with no direct hemodynamic effects [1, 2]. Moreover, it has been proved that it improves LV systolic function, reduces collagen density in the non-infarcted myocardium, and improves myocardial perfusion and the coronary reserve [3, 4]. It is less than a decade since it was first used for the treatment of chronic stable angina. Our anecdotal experience, however, suggests that it could possibly play a role in the reduction of bladder overactivity. Three months ago, a patient with lower urinary tract symptoms (LUTS), suggestive for benign prostatic hyperplasia treated with an a-blocker (AB), reported a significant reduction of storage symptoms after the introduction of ivabradine therapy for the treatment of co-morbitant chronic stable angina. In order to verify if the above-mentioned observation is a correlation or a coincidence, we asked five more patients with diagnosed benign prostatic hyperplasia suffering from storage LUTS (daytime urinary frequency, nocturia and urgency) and chronic stable angina to complete the International Prostate Symptom Score (IPSS) questionnaire prior and after ivabradine treatment. Surprisingly four out of five patients reported a significant reduction of storage LUTS (especially nocturia), resulting in an overall reduction of symptom bothersomeness (from moderately symptomatic to mildly symptomatic). In contrast, the IPSS of the remaining patient remained unchanged. Current knowledge on bladder patho-physiology does not allow for the evaluation of the abovementioned observation. However, the failure of prostate-directed treatments to help all men or all symptoms has led investigators to question the longstanding assumption that the prostate is at the root of all male urinary symptoms [5]. It is now widely recognized that bladder dysfunction plays a role in some, if not most, cases, and recent prospective studies and post-hoc analyses have suggested that pharmacotherapies that target the bladder, such as antimuscarinics, may improve storage urinary symptoms [6]. Indeed, the current mainstays of overactive bladder (OAB) pharmacotherapy are antimuscarinic agents, with mixed actions, including musculotropic (calcium antagonistic) activity [7, 8]. Although the exact mechanism is not clearly understood it could be assumed that it involves interplay between several ionic currents: whole-cell patch clamp studies showed that acetylcholine causes an outward K + current, presumably mediated through Ca 2+ -activated K + channels. Muscarinic M3 receptors are thought to act through increased polyphosphoinositide hydrolysis, inositol 1,4,5-triphosphate (IP 3) K. Stamatiou (&) I. Heretis Faculty of Medicine, Urology Department, University of Crete, Voutes Point, Iraklio, Crete 71110, Greece e-mail: stamatiouk@yahoo.com; stamatiouk@gmail.com

Takotsubo Cardiomyopathy after Spinal Anesthesia for a Minimally Invasive Urologic Procedure

We present the case of a patient who suffered from Takotsubo cardiomyopathy (TCM) immediately after the initiation of subarachnoid anesthesia for a minimally invasive urologic procedure (tension-free vaginal tape (TVT) surgery for stress urine incontinence). TCM mimics acute coronary syndrome and is caused by an exaggerated sympathetic reaction to significant emotional or physical stress. Our patient suffered from chest pain, palpitations, dyspnea, and hemodynamic instability immediately following subarachnoid anesthesia and later in the postanesthesia care unit. Blood troponin was elevated and new electrocardiographic changes appeared indicative of cardiac ischemia. Cardiac ultrasound indicated left ventricular apical akinesia and ballooning with severely affected contractility. The patient was admitted to coronary intensive care for the proper care and finally was discharged. TCM was attributed to high emotional preoperative stress for which no premedication had been administered to the patient. In conclusion, adequate premedication and anxiety management are not only a measure to alleviate psychological stress of surgical patients, but, more importantly, an imperative mean to suppress sympathetic nerve system response and its cardiovascular consequences.

Dedifferentiated Paratesticular Liposarcoma with Osseous Metaplasia

Paratesticular liposarcoma is a rare tumour of the genitourinary track but the most common of all sarcomas in adults. The dedifferentiated variation occurs only in 10% of liposarcoma cases. The typical clinical presentation is similar to an inguinal hernia or a benign lipoma. We present the case of a dedifferentiated paratesticular liposarcoma with osseous metaplasia of the spermatic cord, in a male presented with acute scrotum.

Primary renal angiosarcoma: radiologic-pathologic correlation and literature review

We present a case of primary renal angiosarcoma. We focus on the characteristic striated pattern of the tumor on T2-w MR sequence as well as on other radiological features and correlate them with the pathologic findings. A review of the imaging characteristics of cases published in the literature was subsequently performed.