经直肠超声引导在保留性神经腹腔镜前列腺癌根治术中的应用(附12例报告)

目的:探讨经直肠实时超声引导(TRUS)在保留性神经腹腔镜前列腺癌根治术中(LRP)的作用。方法:2004年6月～2007年3月,对12例TNM分期为T1～T2b的前列腺癌患者行经直肠实时超声引导保留性神经LRP。患者平均年龄62.5岁(57～65岁),术前检查PSA为7.4ng/ml(3.3～9.6ng/ml),IIEF评分平均为17.6分(15～22分)。术中采用TRUS监测神经血管束(NVB)的保留情况。9例保留双侧NVB,3例保留单侧NVB。结果:12例手术均获得成功。平均手术时间分别为270min(210～360min),平均出血量290ml(200～600ml),无切缘阳性患者。9例保留双侧NVB和2例保留单侧NVB的患者均在3～6个月后可成功完成性交。1例保留单侧NVB的患者勃起硬度欠佳,需药物辅助才能完成性交。结论:LRP术中结合TRUS可实时监测NVB的分离,避免NVB的损伤,有助于保留患者阴茎勃起功能。TRUS是保留性神经的LRP术的一种非常实用的新技术。     

前列腺癌患者根治术后尿失禁的预防

目的探讨保护尿道膜部括约肌和神经血管束及重建膀胱颈部对前列腺癌根治术后尿失禁的预防作用。方法对32例前列腺癌采用保护尿道膜部括约肌和前列腺旁神经血管束,并在重建膀胱颈部黏膜充分外翻后的后壁行折叠缝合1针的方法,进行前列腺癌根治术,观察术后尿失禁发生情况。结果经6～72个月随访,全部患者排尿通畅,无肿瘤复发,除2例发生轻度尿失禁外,其余30例在6个月内均恢复尿控能力。结论保护尿道膜部括约肌和前列腺旁神经血管束,在充分外翻膀胱黏膜的重建膀胱颈后壁折叠缝合,能减少前列腺癌根治术后尿失禁的发生。     

保留神经血管束的耻骨后前列腺癌根治术的疗效观察

目的：小结开展保留神经血管束的耻骨后前列腺癌根治术（RRP）的经验和教训。方法：对40例穿刺活检证实的前列腺癌患者行RRP，术前采用新辅助治疗，术中采用保护尿道膜部括约肌和前列腺侧旁神经血管束，并在重建膀胱颈部粘膜充分外翻后的后壁行折叠缝合1针。间断、无张力行残留尿道和外翻的膀胱颈缝合。结果：经3～78个月随访，全部患者排尿通畅，无肿瘤复发；除2例发生轻度尿失禁外，余38例在6个月内均恢复尿控能力。结论：充分做好耻骨后前列腺癌根治术前的准备工作，有利于手术操作；术中保护好尿道膜部括约肌和前列腺侧旁神经血管束，在充分外翻膀胱粘膜的重建膀胱颈后壁折叠缝合，能减少前列腺癌根治术后尿失禁的发生。     

前列腺癌根治术围手术期尿失禁预测因素研究进展

尿失禁严重影响前列腺癌患者术后的生活质量。术前评估并预测患者尿失禁情况不仅有助于临床医生制定个体化手术方案,而且可以给患者一个合理的心理预期。本文主要从术前患者的临床参数,包括年龄、体质指数(BMI)、膜性尿道长度(MUL)、前列腺尖部形态、前列腺突入膀胱度(IPP)等以及术中保留膀胱颈部、神经血管束(NVB)、尿道括约肌等尿控结构保留技术这几个方面,对前列腺癌根治术围手术期的尿失禁预测因素相关研究进展作一综述。     

尿控技术用于经耻骨后前列腺癌根治术80例分析

目的探索保留尿道括约肌手术技巧在前列腺癌根治术中的应用效果.方法本组80例前列腺癌患者,年龄66岁(范围59~75岁);79例前列腺肿瘤限于T2b期以内,1例T3期;78例因PSA升高行术前经直肠超声波(TRUS)引导下的前列腺穿刺活检,Gleason分级3~7分,另2例为TURP后偶发癌;PSA平均8.5ng/ml(范围2.7~44.5 ng/ml).手术前均无尿失禁情况.手术技巧:处理阴茎背深静脉丛采用集束“8”字缝扎;处理前列腺尖部时紧贴前列腺表面分离,并保留前列腺部尿道0.5~1cm;保留膀胱颈部.结果手术后随访12~48个月,18例生化复发,6例尿失禁.结论尿道外括约肌的保留能够减少前列腺癌根治术后尿失禁的发生.     

提高前列腺癌根治术后尿控能力的临床研究

目的：探讨提高前列腺癌根治术后尿控能力的方法。方法：对15例前列腺癌采用保留尿道膜部括约肌及前列腺侧旁神经血管束的方法进行前列腺癌根治术。结果：经6—45个月随访，15例患者排尿通畅，无肿瘤复发，除1例有轻度尿失禁外，余14例6个月内均恢复尿控能力。结论：保留尿道膜部括约肌及前列腺侧旁神经血管束的方法能减低前列腺癌根治术后尿失禁。     

提高腹腔镜前列腺癌根治术后控尿的临床研究

目的 分析总结腹腔镜前列腺癌根治术51例手术控尿技术的经验.方法 回顾性总结腹腔镜前列腺癌根治术患者51例.术前均病理证实前列腺癌诊断.T la～1b 4例(8%),T 1c 15例(29%),T2a 7例(14%),T2b 5例(10%),T2c 20例(39%).结果 腹腔镜下成功完成前列腺癌根治术49例.术后发生尿漏3例,均自愈.术后尿管留置14～45 d,平均16 d.术后随访3～53个月,平均17个月.术后3个月随访51例患者,13例尿失禁;术后6个月随访39例患者,7例尿失禁;术后12个月随访患者20例,5例尿失禁,其中完全性尿失禁1例.前20例和后31例在术后3个月时尿失禁发生率分别为6/20(30%)和7/31(22%),差异有统计学意义(P<0.05).直肠损伤2例,行结肠造口术.术后复发2例,一例行内分泌治疗后停药.另一例肺转移手术后死亡.其余病例前列腺特异抗原<0.2μL.结论 腹腔镜前列腺癌根治术治疗局限性前列腺癌是安全、有效的.术后控尿功能主要与术中前列腺尖部、耻骨前列腺韧带和神经血管束的处理及手术经验相关.     

经腹膜外途径腹腔镜前列腺癌根治术中尿控技巧探讨

目的回顾性总结探讨经腹膜外途径腹腔镜下前列腺癌根治术中处理尿控的方法及技巧。方法临床选择T1～T3a前列腺癌患者44例,年龄为58～82岁,平均年龄为70.5岁。术前前列腺总特异性抗原(TPSA)为8.9～38.6 ng/ml。所有患者术前均行经直肠前列腺穿刺活检,病理明确诊断证实为前列腺癌,平均Gleason评分(5.6±2.5)分,44例患者均行经腹膜外途径腹腔镜下前列腺癌根治术。结果 44例患者均顺利完成手术,手术时间150～410分钟,平均手术时间(220±85)分钟;术中出血量300～1500ml,平均(400±220)ml;术后完全尿控33例(75.0%),部分尿控9例(20.5%)(1周后恢复),完全性尿失禁2例(4.5%)(持续3个月以上),术后病理切缘阳性6例(13.6%);直肠损伤1例,经保守治疗治愈。结论腹腔镜下前列腺癌根治术治疗局限性前列腺癌安全、有效,术后尿控效果与术中神经血管束(NVB)、远端尿道保留长度、正确处理膀胱颈部、膀胱尿道吻合的技巧处理及术者的经验相关。     

经膀胱途径单孔腹腔镜下前列腺癌根治术治疗局限性前列腺癌 8 例报告

目的 探讨经膀胱途径单孔腹腔镜下前列腺癌根治术(transvesical single-site laparoscopic radical prostatectomy,TVSSLRP)的手术技巧和疗效. 方法 选取2010年11月至2011年5月局限性前列腺癌患者8例.年龄37 ～ 65岁,平均58岁.体质指数(body mass index,BMI) 20.0 ～26.0 kg/m2,平均22.5 kg/m2.术前PSA 0.98 ～ 10.04 μg/L,平均7.50 μg/L.国际勃起功能指数(IIEF-5)≥21分7例,＜21分1例.术前穿刺活检病理TNM分期T1c期3例,T2a期5例.Gleason评分2+2分4例,3+2分3例,3+3分1例.D' Amico风险分层均为低风险.全麻下行TVSSLRP,手术由同一名术者完成.使用自制3通道单孔套管建立气膀胱操作通道.远离输尿管开口切开膀胱颈后缘,分离并切断双侧输精管,游离双侧精囊,切开狄氏筋膜,分离前列腺后壁.沿前列腺两侧做环形切口方便暴露前列腺侧韧带,筋膜内层面保留两侧阴茎勃起神经血管束.沿前列腺两侧游离至耻骨后,紧贴前列腺表面切断耻骨前列腺韧带,推开耻骨后血管复合体,分离前列腺尖部,切断尿道.为减少膀胱尿道吻合张力,在膀胱颈两侧和6点处切开膀胱黏膜及黏膜下层,用V-LocTM免打结缝线行膀胱尿道吻合. 结果 本组8例TVSSLRP均顺利完成,无增加辅助通道.手术时间75～ 180 min,平均125 min.术中出血量85 ～450 ml,平均140 ml,无输血患者.术中无手术并发症发生.术后病理检查分期pT2a期3例,pT2b期4例,pT2c期1例;Gleason评分2+2分2例,3+2分4例,3+3分2例;手术切缘均阴性.术后拔除尿管时间9～16d,平均14 d,拔管后控尿均满意,无尿失禁.住院天数13～25 d,平均17d.术后随访12 ～18个月,平均14个月,无尿道狭窄和生化复发发生.术后6个月5例患者勃起功能满意,IIEF-5≥21分. 结论 经膀胱途径单孔腹腔镜下前列腺癌根治术能有效保护阴茎勃起神经和控尿神经,肿瘤根治疗效好.     

前列腺癌根治术中保护控尿功能的体会

目的：减少耻骨后前列腺癌根治术患者术后尿失禁发生率。方法：对16例B超前列腺癌患者行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：16例术后随访3个月-5年，平均13个月。膀胱控尿正常者13例，轻度压力性尿失禁者2例，严重尿失禁者1例。结论：在行耻骨后前列腺癌根治术时，认识尿道括约肌及其支配神经的解剖位置及结构，避免对其损伤可以减少术后尿失禁发生率。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.