bluuebunny/crossref_metadata_2025 huggingface dataset:
Spectrum of histopathologic findings in patients with achalasia reflects different etiologies
Authors: Gockel Ines , Bohl Juergen R E , Doostkam Soroush , Eckardt Volker F , Junginger Theodor
Published: February 2006

Background:  The etiology of achalasia is still unknown. The aim of the present study was to illucidate its underlying pathologies and their chronology by investigation of esophageal specimens in patients undergoing surgery (esophageal resection or myotomy) for achalasia.

Methods:  In 17 patients with achalasia, histopathologic examinations of the esophageal wall focussing on the myenteric plexus were performed. Preoperative diagnosis was based on clinical evaluation, esophagogastroscopy, barium esophagogram in all, and esophageal manometry in eight patients. The median age at the time of surgery was 54 years (range: 14–78 years). In eight cases, the complete esophageal, body and in nine cases a smooth muscle biopsy including parts of the myenteric plexus from the distal part of the esophagus (high pressure zone) was available. The tissue specimens were fixed in formalin and embedded in paraffin. The staining procedures were hematoxylin and eosin (HE), Elastica van Gieson (EvG), and periodic acid–Schiff (PAS) reaction. Immunohistochemical examinations were performed with antibodies against B and T ymphocytes, neurofilament, protein gene‐related product (PGP 9.5), S‐100 protein, myosin, desmin, smooth muscle actin and substance P.

Results:  In 13 of 17 patients, a significant reduction of the number of intramural ganglion cells was present. Common findings were a severe fibrosis of the smooth muscle layer (10/17) and obvious myopathic changes of the smooth muscle cells (5/17). Staining for B and T lymphocytes found signs of inflammation in mucosal and muscular areas. Three patients exhibited a marked invasion of eosinophilic granulocytes of the muscularis propria (eosinophilia). Esophageal carcinoma had developed in three patients (squamous cell carcinoma in two and carcinoma in situ in another patient with Barrett's esophagus and high‐grade dysplasia). Severe inflammatory reactions (neural, eosinophilic and mucosal) dominated in patients with a longstanding history of achalasia (>10 years) as well as a marked endomysial fibrosis.

Conclusions:  The histopathological investigations of the esophageal wall in 17 patients undergoing esophageal resection or myotomy for achalasia suggest that the reduction of intramural ganglion cells might be a secondary change, probably due to inflammation triggered by autoimmune mechanisms or a chronic degenerative process of the central and/or peripheral part of the vagal nerve. The primary lesion could also be a severe myopathy of the smooth muscle cells.
Age and size are the major covariates for prediction of levobupivacaine clearance in children
Authors: CHALKIADIS GEORGE A. , ANDERSON BRIAN J.
Published: February 2006

Background : We aimed to identify and quantify major factors describing the variability of levobupivacaine clearance in children.

Methods : Data from three published studies were used to estimate population pharmacokinetics of levobupivacaine in children who were given epidural regional blockade. Covariate analysis included weight and postnatal age (PNA). Time–concentration profile analysis was undertaken using nonlinear mixed effects models. A one‐compartment linear disposition model with first order input and first order elimination was used to describe the data.

Results : There were 86 children (weight 9.4, sd 5.5, range 1.9–23 kg; PNA 16.1, sd 22.7, range 0.6–98 months). The population parameter estimate for volume of distribution (V) was 189 l·70 kg−1. Clearance (CL) was 5.8 l·h−1·70 kg−1 at 1‐month PNA and increased with a maturation half‐time of 2.3 months to reach 80% of the mature value (22.1 l·h−1·70 kg−1) by 6‐month PNA. The between subject variability (BSV) for V and CL were 48.5% and 35.2%. Overall, 85.7% of the variability of CL was predictable. Weight alone explained 62.4% and the addition of PNA a further 23.3%. Overall, 69.2% of the variability of V was predictable and attributable to weight; V did not change with age in this cohort. The absorption half‐time decreased from 0.36 h at 1‐month PNA to 0.14 h (CV 48.1%) at 6‐month PNA with a maturation half‐time of 0.8 months.

Conclusions : Size and PNA are the major contributors to clearance variability in children. These covariates should be considered when establishing safe epidural infusion regimens. Reduced clearance and slower absorption half‐time contribute to delayed Tmax in neonates and young infants.
Anesthesia for pediatric lithotripsy
Authors: ALDRIDGE RODERICK D. , ALDRIDGE ROLAND C. , ALDRIDGE LOUISE M.
Published: February 2006

Background:  We describe 7 years experience of providing anesthesia for children undergoing lithotripsy in a hospital without pediatric inpatient facilities. A pediatric team, including anesthetist, pediatric nurse along with the equipment travel across the city with the patient from the children's hospital. As a high incidence of postoperative vomiting and discomfort was observed, the effect of increasing intraoperative analgesia and the use of antiemetic medication was examined.

Methods:  From 1998 to 2004, 69 children (49 boys and 20 girls) were anesthetized for 120 procedures: 67 extracorporeal shock wave lithotripsy (ESWL) and 53 endosurgical procedures, consisting of percutaneous nephrolithotomy (29), ureteroscopic laser lithotripsy (17) and percutaneous bladder litholapaxy (7).

The mean age was 5.4 years (10 months to 13 years) and weight 23.7 kg (7.1–59 kg). ESWL was performed initially with a Wolf Piezolith 2300, and after 1999, a Dornier Compact Delta.

Results:  Increased administration of intraoperative analgesia resulted in reduced postoperative analgesia requirements in all the groups, with a significant reduction (P < 0.05) in the endosurgical group. Those who required more postoperative analgesia had more vomiting significantly (P < 0.05).

Conclusions:  For ESWL postoperative pain is dependent on the type of lithotriptor and the resultant stone fragment size created. This study suggests that postoperative vomiting could be reduced more effectively by the increased administration of intraoperative analgesia, than by a single intraoperative dose of an antiemetic drug.
20  VEL015: a novel inhibitor of PI3k/Akt signalling inhibits the progression of prostate cancer and sensitises to existing therapies
Authors: CORCORAN N.M. , MARTIN D. , COSTELLO A.J. , HOVENS C.M.
Published: February 2006

Introduction:  Overactivity of PI3K/Akt signalling is firmly implicated in the progression of lethal prostate cancer. We report on VEL015, a water soluble, orally active agent that blocks PI3K/Akt signalling at the level of Akt and its effects on the progression of experimental prostate cancer.

Methods:  The effects of VEL015 on key components of PI3K/Akt signalling were determined by western blotting with activation state‐specific antibodies and direct in vitro enzymatic assays. Resultant biological effects were determined by proliferation and apoptosis assays. In vivo effects were determined using human prostate cancer cell lines (PC3 and LNCaP) xenografted both subcutaneously and orthotopically. Interaction with androgen deprivation therapy and chemotherapy was explored both in vitro and in vivo.

Results:  In PTEN negative prostate cancer lines VEL015 induces dephosphorylation of Akt. This block is functional in that it induces G1 cell cycle arrest associated with upregulation of p21Cip1 and p27Kip1, and can induce apoptosis in a mechanism that involves a reduction in Bcl‐2 levels. At a daily dose of 0.5 mg/kg po it inhibits the growth of androgen independent prostate cancer by 40–70% at both orthotopic and heterotopic sites without toxicity, and further sensitises these tumours to taxane‐based chemotherapy. By knocking down Akt activation and Bcl‐2 expression, it significantly delays the emergence of androgen independent growth in in vitro and in vivo. Tumour analysis confirms knockdown of the predicted targets, with significant effects seen both in the tumour cells and associated microvasculature.

Conclusions:  VEL015 is a water soluble, orally active agent that inhibits the progression of experimental human prostate cancer.
21  Lactate dehydrogenase‐B is silenced by promoter hypermethylation in human prostate cancer
Authors: CATTO J.W.F. , CROSS S. , PHILLIPS J. , LEIBLICH A. , LEUNG H. , HAMDY F.C. , REHMAN I.
Published: February 2006

In order to identify novel candidates associated with prostate cancer metastasis, we compared the proteomic profile of the poorly metastatic human prostate cancer cell line LNCaP, with its highly metastatic variant LNCaP‐LN3, by two‐dimensional gel electrophoresis. A major protein spot (pI of 5.9 and molecular weight of 37 KDa) was seen in LNCaP cells, but not in LNCaP‐LN3 cells and was identified as Lactate dehydrogenase‐B (LDHB), by tandem mass spectrometry. Furthermore, enzyme kinetic assays and Zymography showed a higher LDH enzyme activity in LNCaP cells compared with LNCaP‐LN3. Bisulfite modified DNA sequencing showed promoter hypermethylation in LNCaP‐LN3 cells but not in LNCaP, Du145, PC3, CWR22 or BPH45 cells. Treatment of LNCaP‐LN3 cells with 5’‐azacytidine caused re‐expression of LDHB transcripts. In tissues, LDHB promoter hypermethylation occurred at a higher frequency in prostate cancer 14/31 (45%), compared to adjacent non‐malignant or benign tissue, 2/19 (11%), (P < 0.025). Immunohistochemistry showed a higher frequency of LDHB expression in benign or non‐malignant tissues, 59/ 73 (81%), compared to cancer cases, 3/53 (6%), (P < 0.001). Absent LDHB expression was also seen in 7/7 (100%) cases of metastatic cancer in bone. Our data are the first to show loss of LDHB expression in prostate cancer, the mechanism of which appears to involve promoter hypermethylation.
24  EMT in human bladder cancer: the fundamental role of snail transcriptional repression
Authors: GILMARTIN B. , FOX E. , MCARDLE E. , DALY P. , HOPKINS A. , HARRISON M. , KAY E. , FITZPATRICK J. , DERVAN P. , MCCANN A.
Published: February 2006

Introduction:  The zinc finger protein Snail is a recognised transcriptional repressor of E‐cadherin (CDH1), resulting in development of the epithelial mesenchymal transition (EMT); a phenotype associated with increased invasiveness and metastatic potential. Snail transcriptionally represses CDH1 by binding to conserved E‐box elements in its promoter sequence. A number of EMT‐related genes exist possessing evolutionarily conserved, promoter‐associated, E‐box elements. We hypothesise that transcriptional repression of these genes by Snail is also instrumental in EMT.

Materials and Methods:  Phylogenetic analysis, using the Database of Transcriptional Start Sites website (http://dbtss.hgc.jp/), was performed to identify candidate genes. Genes were selected for experimental characterisation based on functional relevance to EMT and/or promoter structure similarity to CDH1. For each candidate gene promoter, primers were designed to amplify the putative E‐box containing region. We employed the chromatin immunoprecipitation (CHiP) assay to demonstrate the DNA binding ability of Snail to a number of these candidate genes. E‐cadherin negatively expressing cell lines sourced from the American Type Culture Collection served as models to investigate transcriptional repression of candidate genes by Snail using realtime PCR.

Results:  Transcriptional repression of a number of candidate genes by Snail was demonstrated using the CHiP assay.

Conclusion:  Transcriptional repression of E‐cadherin by Snail is established. We have shown that Snail also causes downregulation of novel EMT‐related genes. Snail downregulation of a combination of these genes may prove to be an expression signature of recurrence in low grade urothelial carcinoma of the bladder.
27  Pathological classification of urothelial neoplasms: practical choices for patient care
Authors: CAMPBELL P.A. , CAMPBELL C.M. , NICOL D.L. , MACTAGGART P.
Published: February 2006

Introduction:  Morphological classifications systems that stratify neoplasms according to biological potential must define categories that are reproducible among practitioners, otherwise they create the heterogeneous population that they wish to avoid. This is particularly important for the classification of bladder neoplasms where follow‐up protocols are based on the risk of recurrence and progression. This risk is assessed according to their morphological classification.

Materials and Methods:  Previously forty‐nine cases of superficial bladder cancer (G1‐3pTa) representing an initial diagnosis of transitional cell carcinoma made in 1990 were identified and re‐graded using the 1998 WHO/ISUP classification by two pathologists. Inter‐observer agreement was assessed using Cohen weighted K statistics. After re‐classification the clinical follow‐up was reviewed retrospectively, and episodes of recurrence and progression noted. This paper compares those results to the same group of patients classified using the 1973 WHO scheme and followed up in a similar manner to try to determine if one system show better patient benefit over the other.

Results:  The interobserver agreement of pathologists using the 1998 WHO/ISUP scheme is moderate overall, but there is high disagreement when pathologists are asked to differentiate papillary urothelial neoplasms of low malignant potential from low grade carcinoma. The progression rates were very low for PUNLMPs and low grade carcinoma, but moderate for high grade carcinoma.

Conclusions:  The 1998 WHO/ISUP classification of urothelial neoplasms requires certain discriminations that cannot be reliably made by practitioners. Modifying the scheme to create categories of low grade neoplasm and high grade neoplasm would markedly increase its practical value to patients without significantly altering patient care.
29  Changing patterns of radical cystectomy at St. Vincent's Hospital, Melbourne
Authors: BRENNAN J.P. , SLAVIN J. , TEMELCOS C. , CLARKE A. , NIALL O. , ASOPA R. , WILLIAMS E.D. , GOAD J.
Published: February 2006

Purpose:  To collect clinical, pathological and outcome data on all patients who have undergone radical cystectomy at St. Vincent's between 1985 and 2005.

Methodology:  A retrospective chart review was performed of all patients who had undergone cystectomy (patients identified using ICD codes). Detailed information was obtained from operation reports and inpatient notes. Further information was obtained from other treating hospitals and private rooms. Outcome data was checked against the Cancer Council of Victoria Deaths Registry. This series was then compared against other large published series, including a St. Vincent's Hospital cohort (1963–1977).

Results:  One hundred and seventeen patients underwent total cystectomy during this 20 year period. The main indication for radical cystectomy was muscle‐invasive transitional cell carcinoma (TCC), with 55% of patients having T3 or T4 disease. Only 12% of patients had node positive disease, which is a reflection of the selective use of pelvic lymphadenectomy (56% patients Nx). Median follow up of cancer survivors was 71 months (6.5–132). 30% of patients had a history of superficial TCC. The postoperative mortality rate (occurring within 60 days or before discharge) was 6%. Only 14% patients had adjuvant chemotherapy. 57% of patients developed a recurrence with an overall five‐year survival of 38%.

Conclusion:  In comparison to North American and European series, our five‐year survival is lower but a higher proportion of patients have muscle‐invasive (T2–T4) disease. Postoperative mortality rates are comparable to other institutions, and importantly, a 60% reduction in postoperative mortality has occurred at our institution over the last 40 years.
33  Development and maturation of human prostate from embryonic stem cells in vivo
Authors: RISBRIDGER G. , FRYDENBERG M. , CROWIN P.A. , TAYLOR R.A. , CUNHA G.R. , PERA M. , TROUNSON A.O. , PEDERSEN J.
Published: February 2006

The study of human prostate development is limited by the availability of young normal tissue and the lengthy process from fetal development to maturation. The rodent is commonly used as a model to study human prostate development, maturation and disease, while immortalised or genetically modified cell lines are frequently used to study prostate differentiation and carcinogenesis. These approaches have limited utility when extrapolating findings to humans, however they have provided controversial evidence for the early origins of adult prostate disease specifically BPH, inflammation and prostate cancer. It is imperative we establish new models that accurately mimic human prostate development and maturation. Using rodent mesenchyme to establish reciprocal mesenchymal epithelial cell interactions with human embryonic stem cells (hESC) we report the development and maturation of undifferentiated hESC to fetal and mature human prostate tissue expressing PSA. hESC of different genetic sex generated ductal glandular structures expressing androgen receptor, estrogen receptors, Nkx3.1 and p63 and PSA. Seminal vesicle mesenchyme (SVM) recombined with hESC demonstrated the inductive properties of SVM across germ layers and predominantly generated prostatic tissue expressing PSA, rather than vesicular tissue expression lactoferrin. Androgen withdrawal caused tissue regression and atrophy. This model provides a novel model of human prostate development and maturation and shows species conserved signalling mechanisms that could extend to integumental, gastrointestinal and genital tissues.
38  Antegrade ejaculation can be preserved after lumbar sympathetic nerve sparing during post chemotherapy retroperitoneal lymph node dissection for testicular cancer
Authors: PATEL M.I. , GURNEY H.
Published: February 2006

Resection of residual masses in the retroperitoneum (RPLND), following chemotherapy for testicular cancer was traditionally performed by full bilateral dissection. To minimise the loss of antegrade ejaculation (AGE), a new technique of modified template dissection (contralateral lymphnodes were not dissected in order to preserve the lumbar sympathetic nerves and maintain AGE) was later developed. More recently, lumbar sympathetic nerves have been individually dissected and preserved (sparing) in an attempt to maintain AGE. In this study we report on 18 consecutive men with postchemotherapy testicular cancer who under went RPLND. In each man the limit of dissection and number of sympathetic nerves “spared” or left undissected along with the lymphnodes (modified template) were recorded prospectively. Postoperatively all men were questioned about their ejaculation status. Of the 18 men, 10 men had left sided primary testicular tumours. 10 men had para‐aortic lymphnode masses, eight had interaortocaval masses and one also had a paracaval mass. Masses ranged from 155 mm to 10 mm. Fourteen men had bilateral resections and four men had unilateral resections because of extremely small masses. With regards to nerve preservation, two men had complete sympathetic nerve resection and neither has AGE. All other men had between one and five nerves spared, and all these men have preserved antegrade ejaculation. Median follow up is 12 months, and no man has yet suffered an in‐field recurrence. In conclusion, preservation of even one lumbar sympathetic nerve can maintain AGE, and does not appear to compromise tumour eradication.
40  A reliable method for simplifying flexible uretero‐renoscopy in patients with urinary diversions
Authors: ELMES M.R. , LAWRENTSCHUK N. , BOLTON D.M.
Published: February 2006

Introduction:  Access to the upper urinary tract to exclude or treat recurrent transitional cell carcinoma (TCC) is not infrequently required in patients who have previously undergone urinary diversion in the management of invasive bladder carcinoma. This can be a technically difficult procedure. We describe a method which simplifies the diagnosis and treatment of upper tract TCC posturinary diversion.

Patients and Methods:  Four patients who had previously required urinary diversion (3 ileal conduit, 1 ileal neobladder) underwent flexible uretero‐renoscopy after antegrade skinny‐needle renal puncture and placement of a guidewire down the ureter into the ileal conduit. The guidewire is then externalised. A second guidewire is placed in a retrograde fashion using a double lumen catheter or an exchange guidewire set, and this second guidewire is then used as a guide for insertion of the flexible ureteroscope. This guidewire may be replaced repeatedly during the procedure to facilitate multiple biopsies.

Results:  All patients were treated successfully and without complication from placement of the percutaneous guidewire. Operating time was under one hour in all cases.

Conclusions:  Flexible uretero‐renoscopy of the upper urinary tract postileal urinary diversion can be made easier and less time consuming by preliminary placement of a percutaneous antegrade guidewire.
43  Large animal models of renal warm ischaemia/reperfusion injury. Comparison of dog versus pig
Authors: FORMAN C.J. , NICOL D. , JOHNSON D.
Published: February 2006

Introduction:  With the advent of laparoscopic partial nephrectomy interest has focused on renal tolerance of, and treatments for, warm I/R injury. Most in vivo work is done in rodent models, but findings are often not replicated in humans. Thus experiments often need to be replicated in a higher mammalian model, prior to human trials. Here I present the pros and cons of two of the most commonly used higher models.

Materials and Methods:  Eleven dogs underwent nephrectomy and clamping of the contralateral renal artery for one hour. They were followed up with daily blood tests for 5 days. Seven pigs underwent a 2‐stage procedure. First a right nephrectomy, followed a week later by clamping of the left renal artery for one hour. They were then followed up with 24 h urine collections and daily blood tests.

Results:  Serum creatinine concentration expressed as mean ± SEM in micromoles / litre.

Pre‐op
Day 1
Day 2
Day 5

Dog
82 ± 3
239 ± 38
279 ± 61
266 ± 71

Pig
92 ± 9
132 ± 14
123 ± 13
89 ± 7

Conclusion:  The choice of animal model can make or break a project. The researcher should consider availability, homogeneity, cooperativeness and cost of the animal, together with correlation of the histological pattern of injury with humans, when choosing. On balance, pigs are more effort, but reward the researcher with better results, using fewer animals.
45  Pretransplant CT estimated renal volume is not a predictor of graft function post transplantation
Authors: HADLEY A.J. , HAWLEY C. , NICOL D.
Published: February 2006

Introduction:  There appears to be a critical nephron mass required to handle the metabolic demands of the body. The relationship between an individual's glomerular number and their weight is called the ‘nephron dose’. Inadequate nephron dose results in hyperfiltration and renal dysfunction. In healthy kidneys, there is a linear relationship between the renal weight and the glomerular number, but as it is impossible to measure the donor renal weight prior to excision, various surrogate measures have been reported. These include BMI, ultrasound and MRI volume studies. No studies assessing CT estimated renal volumes have previously been reported.

Methods:  In this retrospective cohort study, we analysed the data from 48 patients receiving live‐donor renal transplants between June 2001 and November 2003 at our institution. The donor renal volume‐recipient weight (Vol/Wt) ratio was calculated for each patient and compared to the GRF at 1, 3 and 6 months posttransplantation. Vol/Wt ratio to GFR was analysed as continuous, categorical and tertile variables.

Results:  There was no relationship found between Vol/Wt ratio and GFR at 1, 3 or 6 months posttransplantation.

Conclusion:  Using CT renal volume estimations as a surrogate for nephron number does not allow one to predict short term renal function after living donor transplantation.
46  Laparoscopic versus open living donor nephrectomy: a contemporary series from a single centre
Authors: POWER R.E. , PRESTON J.M. , MARTIN I. , WALL D. , GRIFFIN A. , NICOL D.L.
Published: February 2006

Introduction:  Laparoscopic living donor nephrectomy offers potential advantages to the donor and has become a routine procedure for live kidney procurement worldwide. Since 2000 our live donor patients have been offered a laparoscopic nephrectomy.

Patients and Methods:  Between February 2000 and August 2005 we performed 183 donor‐recipient operations at our institution (ODN = 83 and LND = 100). We prospectively collected information on all donors and recipients for the same period to audit our experience with the first 100 LDN‘s. Patients made their operative choice following discussions regarding the unit experience and literature information. We present our findings with specific emphasis on donor operative details and early recipient graft outcome.

Results:  Donor and recipient age, gender, body mass index, HLA mismatches, warm ischaemia and vascular anastomotic times did not significantly differ between the two groups. There were two conversions to an open operation in the LND group and neither impacted upon recipient graft outcome. The mean operative duration was 178 ± 38 for the LDN and 159 ± 34 min for the ODN (P < 0.05). The mean length of hospital stay was 4.7 ± 1.2 days in the LND group versus 6.8 ± 1.5 days in the ODN group (P < 0.05). There was one case of delayed graft function in both groups. Serum creatinine at 1, 6 and 12 months did not differ significantly between either groups. Vascular and ureteric complications and lymphocoele rates were similar in both groups.

Conclusions:  Our contemporaneous series demonstrates the safe introduction of a laparoscopic living donor programme without compromise towards donor patient safety or allograft outcome.
5  Prostate biopsy – common practices and differences amongst Australian and New Zealand urologists
Authors: RAO R. , THOMAS B. , DUNGLISON N. , GARDINER R.A. , YAXLEY J. , PETERS J. , COSTELLO A.
Published: February 2006

Purpose:  Studies out of the United States and United Kingdom show great variability in practices relating to prostatic biopsy. This survey was performed to evaluate current practices in Australia and New Zealand.

Methods:  Questionnaires were sent to Australian and New Zealand Urologists and Trainees on the database of the Urological Society of Australasia.

Results:  Significant variability exists with regard to antibiotic prophylaxis, bowel preparation; analgesic use; number of cores taken; and repeat biopsy practices. Most urologists (91%) perform their own biopsies. 9% refer to another urologist or radiologist. Transrectal biopsy is the favoured approach in 97%. Most urologists (96%) use antibiotic prophylaxis with the quinolone antibiotics being the most commonly used. Only 42% use bowel preparation for their biopsies. Analgesia is used in 79% with equal numbers using sedation and periprostatic nerve block. 77% take 10 cores or more for first biopsy. 28% do not inform their patients of a false negative rate with TRUS biopsy of the prostate. There were 36% and 60% who would not re‐biopsy for HGPIN and ASAP respectively.

Conclusions:  Prostate biopsy is a commonly performed procedure to diagnose carcinoma of the prostate. Despite significant variability, most Urologists and Trainees in Australia and New Zealand have safe biopsy protocols, given the evidence that is currently available. Evidence supports the use of analgesia and repeating biopsy for HGPIN and ASAP.
51  Laparoscopic suturing: effect of instrument handling on suture strength
Authors: BARIOL S.V. , STEWART G.D. , TOLLEY D.A.
Published: February 2006

Introduction:  The limited operative field of laparoscopic surgery necessitates repeated instrument handling of suture material, which is discouraged in conventional open surgery. The quantitative effect of instrument handling on suture material has not previously been investigated. The aim of this study was to assess the effect of instrument trauma on various suture materials by laparoscopic needle holders and forceps.

Materials and Methods:  Three sutures of various gauge and material, 2‐0 and 3‐0 Polyglactin 910 and 2‐0 Poliglecaprone 25, commonly used in laparoscopic urological reconstruction, were tested. Controlled damage was performed by grasping the suture without tension between the jaws of either a toothed laparoscopic grasping forceps or a laparoscopic needle holder. Physical testing was performed using an Instron 5564 computer controlled tensile testing, which measured suture extension and tensile strength. Samples were examined using scanning electron microscopy.

Results:  There was no difference in mean percentage extension or tensile strength when comparing suture types damaged with laparoscopic graspers and controls regardless of their gauge or material. Following controlled damage with laparoscopic needle holders, % extension of damaged sutures was significantly lower compared with undamaged sutures. Tensile strength was significantly lower for 3‐0 Vicryl and 3‐0 Monocryl after damage with laparoscopic needle holders compared with undamaged sutures, but not 2‐0 Vicryl.

Conclusion:  The handling of suture material with laparoscopic instruments, especially needle holders, results in surface damage to the suture, which impacts on the suture mechanics. Limiting surface damage to suture material requires careful technique, avoiding shear force, minimising handling of the suture, and using shorter suture lengths.
52  Laparoscopic pyeloplasty – evolution of a new gold standard
Authors: MOON D. , EL‐SHAZLY M. , CHANG C. , GIANDUZZO T. , EDEN C.
Published: February 2006

Objectives:  We report the largest series of laparoscopic dismembered pyeloplasty for treatment of primary and secondary uretero‐pelvic junction (UPJ) obstruction, reviewing the current status of this procedure.

Methods:  A total of 170 consecutive cases of laparoscopic pyeloplasty (156 for primary and 14 for secondary UPJ obstruction) were performed or supervised by a single surgeon (C.G.E). A four port extraperitoneal approach was used in all but three cases, which were performed transperitoneally.

Results:  Median operative time was 140 min. The complication rate was 7.1% and conversion rate was 0.6% with no conversion in the last 161 cases. The median postoperative hospitalisation was 3 nights. Crossing vessels were encountered in 42% of cases and in 11 patients coexisting renal calculi were successfully removed. At a median follow‐up of 12 months, the success rate was 96.2%.

Conclusions:  Laparoscopic dismembered pyeloplasty produces functional results comparable to that of open surgery with the advantages of a minimally invasive procedure. Our results are consistent with previous series and support the view that laparoscopic pyeloplasty is moving rapidly towards replacing open surgery as the gold standard in treatment of UPJ obstruction.
55  Local anaesthetic reduces postoperative analgesic requirements in laparoscopic urological surgery
Authors: KHAIRA H.S. , WOLF J.S.
Published: February 2006

Objective:  To determine if local anaesthetic reduces patient discomfort following laparoscopic urological surgery.

Methods:  Sixty‐seven patients undergoing laparoscopic urological surgery were randomly assigned to either the treatment (0.5% bupivacaine) arm or the placebo (0.9% normal saline) arm. Patients, surgeon and data collector were blinded. The port sites and the hand assist port site (when present) were infiltrated at the outset of the procedure. Postoperative pain was determined with a standardized 10 point visual analog scale at consistent intervals.

Results:  Thirty‐three individuals were treated with the placebo (13 standard laparoscopic [SL] and 20 hand assisted laparoscopic [HALS]) and 34 with bupivacaine (17 SL and 17 HALS). Average pain scores for the placebo vs. bupivacaine group at 4, 12, 24 h were 3.9, 3.1, 3.6 vs. 3.0, 2.1, 2.0 (P < 0.10). Mean use of morphine for the placebo group vs. bupivacaine group was: 26.1 mg (range 0–91.9) vs. 15.4 mg (range 0–49.5) at 12 h (P < 0.05), 43.5 mg (range 0–136.9) vs. 26.2 mg (range 0–71.0) at 24 h (P = 0.07) and 50.4 mg (range 0–154.9) vs. 28.3 mg (range 0–71.0) for total hospital stay (P < 0.05). In multivariable anova, use of bupivacaine, but not SL vs. HALS, was associated with reduced morphine use at all three time points (P < 0.05).

Conclusions:  At the outset of laparoscopic urological surgery in the upper retroperitoneum, port site and other incision infiltration with a long acting local anaesthetic reduces postoperative parenteral opioid requirements when compared with placebo controls.
56  Prostate glands larger than 75 cc result in worse outcomes following radical prostatectomy: implications for registrar training
Authors: PATEL M.I. , CHAN W. , WOO H. , LAU H. , DRUMMOND M. , BROOKS A.
Published: February 2006

Introduction and Objective:  Open radical prostatectomy is a difficult and complex operation to teach residents. Many patient factors can increase the complexity of the operation, with the majority not being predictable prior to the operation. We hypothesised that large prostate glands (>75 cc) would result in increased difficulty, higher intraoperative complications, and subsequently poorer cancer and functional outcomes.

Methods:  A retrospective analysis of the records of patients in our database of radical prostatectomies performed at Westmead Hospital. Patients operated on by the training urology registrar were identified and further analysed. Intraoperative as well as postoperative complications, pathology results and postoperative gain of potency and continence were evaluated.

Results:  Between 2/6/1998 to 14/8/04, 181 open radical prostatectomies were performed at Westmead Public Hospital by the training registrar. Preoperative variables revealed that the majority of these patients had large volume cancer (171 pts with cT2 cancer, 70 pts with Gleason Score ≥7). PSA ranged from 1.2–27 ng/ml (median 6.9 ng/ml). Prostate size ranged from 11–112 cc (median 31 cc) measured by TRUS ultrasound. Correlation between calculated TRUS volume and prostate weight at surgery was high (r = 0.93). Prostate glands greater than 75 cc were associated with older age (P = 0.001), longer operation time (P < 0.001)and higher estimated blood loss (P < 0.001). Postoperatively, prostate glands >75 cc required median of 7 vs 3 months to achieve continence (P < 0.001). At a median follow time of 45 months, men with prostates <75 cc had a 62% chance of achieving potency compared to 10% of men who has glands >75cc (P < 0.001). Oncologically, larger prostates had less positive surgical margins (P = 0.006) and less PSA recurrence (P = 0.024).

Conclusions:  Prostates larger than 75 cc result in longer operative times, higher blood loss as well as poorer continence and potency. Patients should be counselled accordingly and trainers should be prepared to supervise more carefully when teaching inexperienced trainees.
58  Robotic laparoscopic radical prostatectomy for non‐laparoscopic surgeons ‐ what is the learning curve?
Authors: BOUCHIER‐HAYES D.M. , VAN APPLEDORN S. , CROWE H. , PETERS J.S. , COSTELLO A.J.
Published: February 2006

Introduction:  Laparoscopic radical prostatectomy (LRP) has been shown to have many advantages over open surgery, but has proven difficult for many to become adept at. The use of the Da Vinci® robotic system greatly facilitates the performance of LRP. We set out to analyse how many cases it takes to become proficient at Robotic Assisted Laparoscopic radical Prostatectomy (RALRP).

Methods and Methods:  Two experienced open surgeons began performing RALRP using the Da Vinci® robotic system in December 2003. Duration of various steps were measured prospectively. Results were grouped sequentially in groups of 10 patients and analysed statistically to determine at what point these results reflected increased operative proficiency. Surgeons results were analysed separately to provide internal validation.

Results:  One hundred and ten consecutive patients were evaluated. Overall operative times for both surgeons decreased significantly (P < 0.05) over the first 30 cases after which they plateaued at an average of 191 min (36.3% reduction). Actual operative time also decreased significantly (P < 0.01) at or before the 30th case until plateauing at 146 min (39% reduction).

Conclusion:  RALRP is a procedure that can be mastered much more quickly than standard LRP by experienced open surgeons inexperienced in laparoscopic surgery, with surgical proficiency being attained at/before the 30th case.
64  Pilot study of local anaesthetic infusion pump for analgesia following radical prostatectomy
Authors: WOO H.
Published: February 2006

Introduction:  The PainbusterTM is a local anaesthetic(LA) infusion pump placed into wounds as a means of reducing postoperative pain. A reservoir is filled with LA under pressure and a controlled constant output of LA is delivered into the wound immediately overlying the muscular closure using epidural‐like catheters. The use of these devices have not previously been reported in the specific setting of open radical prostatectomy. The objective of this pilot study was to assess the impact of the PainbusterTM on postoperative pain scores and narcotic analgesic requirements with a view to providing a basis for power calculations for a randomised study with or without the use of a PainbusterTM.

Methods:  Analgesic requirements of 24 consecutive patients undergoing radical prostatectomy were studied. The first 12 (Group A) had PainbusterTM devices in addition to Pain Controlled Analgesia (PCA) devices and the following 12 (Group B) only had PCA devices. As part of standard ward protocol, patients are scored for pain using a 0 to 10 numerical pain score every 1 to 2 h unless asleep.

Results:  Conclusions:  Statistical significance was not to be expected given the small numbers in each limb. The PainbusterTM does significantly reduce the maximum pain the patient will experience at any time during the postoperative period in hospital. Use of the PainbusterTM appears to halve narcotic analgesic requirements following radical prostatectomy and allows for some basis upon which appropriate power calculations can be made for Phase 3 studies.

Group A
Group B
P‐value

Mean pain score in first 24 h
1.67
2.74
0.06

Mean pain score overall
1.70
2.50
0.10

Masimum pain score reported
3.25
5.91
<0.002

Morphine equivalent requirement
26
51
0.12

Length of stay
3.4
5.1
0.10
65  Multi‐resistant Escherichia coli septicaemia following transrectal ultrasound guided prostate biopsy – an emerging risk
Authors: DAVIDSON A.‐J. , LAWRENTSCHUK N. , JENNENS I.D. , SUTHERLAND M. , WEBB D.R.
Published: February 2006

Introduction:  Transrectal ultrasound (TRUS) guided biopsy of the prostate is the standard procedure for diagnosing prostate carcinoma. Complications range from discomfort and bleeding to asymptomatic bacteruria and sepsis. Rarely, sepsis is fatal. E. coli is the most common pathogen causing infection and although no international standard for the use of prophylactic antibiotics exists their use has decreased the incidence of infection to around 2%. Worldwide the incidence of multi‐resistant E. coli (MREC) is increasing, and we report two cases of septicaemia secondary to MREC infection postprostate biopsy.

Methods:  We performed a review of case records involving postprostate biopsy MREC infection. A comprehensive literature review of TRUS guided biopsy of the prostate was also performed.

Results:  All patients in our series had MREC cultured following TRUS guided biopsy of the prostate. All received the same prophylactic antibiotic regime (norfloxacin and gentamicin). They required admission to hospital for intravenous antibiotics and in two cases inotropic support, eventually making full recoveries. All had a history of recent travel to a developing country whilst two had self‐limiting diarrhoea and this is the first report in the English literature of MREC following prostate biopsy. Other risk factors for acquiring multi‐resistant urinary tract infections have been identified including age and previous quinolone therapy.

Conclusion:  Antibiotic prophylaxis for biopsy of the prostate, being predominantly quinolones, will continue to aid in reducing morbidity. However, with the prevalence of MREC increasing current regimens will not cover such organisms potentially leading to sepsis. In our cases travel to developing countries appeared to be a risk factor for being colonised with MREC. We believe through careful history risk factors for multi‐resistant urinary tract infection including travel may alert doctors to the potential risk of MREC at the time of biopsy leading to the addition of a broader spectrum antibiotic such as intravenous meropenem.
67  Double blind randomised controlled trial of topical cophenylcaine forte spray in prostatic biopsy
Authors: GOGIA R. , LLOYD M.
Published: February 2006

Introduction:  It is well known patients find prostate biopsy uncomfortable, and in many instances painful. There may also be discomfort and embarrassment of postbiopsy bleeding. Cophenylcaine Forte spray (Lignocaine Hydrochloride 5.0%, Phenylephrine Hydrochloride 0.5%) is a drug with local anaesthetic and vasoconstrictor properties currently used as a topical preparation in Ear, Nose and Throat surgery. It is suggested that topical application of Cophenylcaine Forte spray to the rectal mucosa prior to prostate biopsy will reduce the discomfort associated with the insertion of the ultrasound probe into the rectum and possibly reduce postbiopsy bleeding. We are unaware of any previous studies addressing these issues.

Methods:  After human ethics committee approval and informed consent, 30 consecutive patients presenting for prostate biopsy were randomised to receive either Cophenylcaine Forte spray or placebo saline spray topically to the rectal mucosa ten minutes prior to biopsy. All patients then proceeded to have a 12 core prostate biopsy performed with bilateral periprostatic block (Lignocaine 1.0%, 10 ml) under transrectal ultrasound guidance by a single operator. An investigator questionnaire consisting of pre and postbiopsy pulse and blood pressure and a visual analogue score for observed patient discomfort and bleeding were completed by the single investigator. In addition, a patient questionnaire 30 min postprocedure and the day after the procedure were also completed assessing discomfort and postbiopsy bleeding from the patient's perspective. Patients with painful anorectal abnormalities or anal stenosis were excluded and biopsied under general anaesthetic.

Results:  No statistically significant differences were observed between the two treatment groups for any of the parameters considered. Specifically there was no improvement in rectal discomfort or bleeding with the use of Cophenylcaine Forte spray.

Conclusion:  Cophenylcaine Forte topical rectal spray appears to make no difference to patient discomfort, postbiopsy bleeding or ease of the procedure during transrectal ultrasound and prostate biopsy.
68  Junior medical officers and basic urology: a questionnaire
Authors: LOUIE‐JOHNSUN M. , MUNZEL B. , MURPHY D.
Published: February 2006

Purpose:  Urological disease is very common. In certain settings, urological assistance may not be easily accessible. Undergraduate and postgraduate programs must provide a basic level of training to deal with common problems. We assessed JMOs (junior medical officer) confidence and capability in managing every day urology.

Methodology:  At a regional hospital, a questionnaire was distributed to 42 JMOs. The number of and confidence in performing basic urological procedures were assessed. A second part involved multiple choice questions on clinical scenarios.

Results:  Response rate was 100% with 15 interns, 13 residents and 14 registrars from various specialties returning completed questionnaires. Eight (19%) JMOs had previously worked in a urology unit (UJMOs). 54% of HMOs had inserted >10 male urethral catheters compared to 28% >10 female catheters. They were also more confident with male catheters (51% vs. 18% very confident). Despite 18(43%) JMOs performing >30 rectal examinations, only 1 felt very confident in assessing prostate gland characteristics. UJMOs had performed more and were more confident (P < 0.05) in these simple procedures. Only six JMOs (14%) had inserted a suprapubic catheter. Overall, only 59% answers to clinical scenarios were correct.

Conclusion:  This simple questionnaire highlights JMOs perceived deficiencies in areas such as female urethral catheterization and interpretation of rectal examination. Questionnaires like this can be used to help structure undergraduate curriculum and postgraduate workshops to improve confidence and competence.
7  Positive margin rates in patients with a single positive core on extended TRUS biopsy
Authors: DANGERFIELD D. , SAMARATUNGA H. , YAXLEY J.
Published: February 2006

Introduction:  Extended TRUS biopsy (12 biopsies or more) is now a standard technique performed in many centres. The management of small volume prostate cancer (<0.05cc) found in a single TRUS biopsy is controversial and may have implications in nerve‐sparing versus non‐nerve sparing radical prostatectomy. The aims of this study are:

• To assess the incidence of prostate cancer in the unaffected contralateral prostate lobe on final histopathology

• To assess the incidence of extracapsular extension and margin status in the ipsilateral and contralateral lobes

Patients and methods:  Of 897 radical prostatectomy specimens examined through Sullivan Nicolaides Pathology between 2002 and 2005, 78 had a single positive core in preoperative TRUS biopsy. Histopathalogy, PSA and Gleason sum were reviewed.

Results:  For patients with a Gleason sum of 6 on TRUS biopsy the mean PSA was 7.00 mcgm/dl. A majority (85%) of the positive cores had low volume disease with tumour occupying less than 30% of the core. Of those with Gleason 3 + 3 = 6 on TRUS biopsy, 34% had their Gleason sum upgraded on final histopathology. Ipsilateral positive margin was seen in 14% of cases. Contralateral positive margin was present in only 2.8% of cases despite tumour being found in 61% of cases in the contralateral lobe on final histopathology.

Conclusion:  This study shows that in patients with a single positive core of low volume disease, the incidence of contralateral margin involvement on final histopathology is very low. This data is useful in counselling patients who intend to undergo nerve sparing radical prostatectomy.