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The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II-III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5% in GDT group and 38.1% in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs. 9.5% in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs. 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol. [ABSTRACT FROM AUTHOR]

During laparoscopic surgery, the role of PEEP to improve outcome is controversial. Mechanistically, PEEP benefits depend on the extent of alveolar recruitment, which prevents ventilator-induced lung injury by reducing lung dynamic strain. The hypotheses of this study were that pneumoperitoneum-induced aeration loss and PEEP-induced recruitment are inter-individually variable, and that the recruitment-to-inflation ratio (R/I) can identify patients who benefit from PEEP in terms of strain reduction. Sequential study. Operating room. Seventeen ASA I-III patients receiving robot-assisted prostatectomy during Trendelenburg pneumoperitoneum. Patients underwent end-expiratory lung volume (EELV) and respiratory/lung/chest wall mechanics (esophageal manometry and inspiratory/expiratory occlusions) assessment at PEEP = 0 cmH 2 O before and after pneumoperitoneum, at PEEP = 4 and 12 cmH 2 O during pneumoperitoneum. Pneumoperitoneum-induced derecruitment and PEEP-induced recruitment were assessed through a simplified method based on multiple pressure-volume curve. Dynamic and static strain changes were evaluated. R/I between 12 and 4 cmH 2 O was assessed from EELV. Inter-individual variability was rated with the ratio of standard deviation to mean (CoV). Pneumoperitoneum reduced EELV by (median [IqR]) 410 mL [80–770] (p < 0.001) and increased dynamic strain by 0.04 [0.01–0.07] (p < 0.001), with high inter-individual variability (CoV = 70% and 88%, respectively). Compared to PEEP = 4 cmH 2 O, PEEP = 12 cmH 2 O yielded variable amount of recruitment (139 mL [96–366] CoV = 101%), causing different extent of dynamic strain reduction (median decrease 0.02 [0.01–0.04], p = 0.002; CoV = 86%) and static strain increases (median increase 0.05 [0.04–0.07], p = 0.01, CoV = 33%). R/I (1.73 [0.58–3.35]) estimated the decrease in dynamic strain (p ≤0.001, r = −0.90) and the increase in static strain (p = 0.009, r = −0.73) induced by PEEP, while PEEP-induced changes in respiratory and lung mechanics did not. Trendelenburg pneumoperitoneum yields variable derecruitment: PEEP capability to revert these phenomena varies significantly among individuals. High R/I identifies patients in whom higher PEEP mostly reduces dynamic strain with limited static strain increases, potentially allowing individualized settings. • Optimal PEEP for laparoscopy is debated. Aeration loss and recruitment vary among patients, warranting personalized settings. • IIn this study, 17 patients undergoing robot-assisted prostatectomy during Trendelenburg pneumoperitoneum were studied. • Pneumoperitoneum variably reduced FRC. PEEP 12 cmH 2 0 yielded variable recruitment, leading to diverse effects on lung strain. • EELV-derived R/I well reflected the effect of PEEP on lung strain, identifying patients benefiting the most from higher PEEP. [ABSTRACT FROM AUTHOR]

Purpose: Recent studies have suggested an α/β ratio in prostate cancer of 1.5–3 Gy, which is lower than that assumed for late-responsive normal tissues. Therefore the administration of a single, intraoperative dose of irradiation should represent a convenient irradiation modality in prostate cancer. Materials and Methods: Between February 2002 and June 2004, 34 patients with localized prostate cancer with only one risk factor (Gleason score ≥7, Clinical Stage [cT] ≥2c, or prostate-specific antigen [PSA] of 11–20 ng/mL) and without clinical evidence of lymph node metastases were treated with radical prostatectomy (RP) and intraoperative radiotherapy on the tumor bed. A dose-finding procedure based on the Fibonacci method was employed. Dose levels of 16, 18, and 20 Gy were selected, which are biologically equivalent to total doses of about 60–80 Gy administered with conventional fractionation, using an α/β ratio value of 3. Results: At a median follow-up of 41 months, 24 (71%) patients were alive with an undetectable PSA value. No patients died from disease, whereas 2 patients died from other malignancies. Locoregional failures were detected in 3 (9%) patients, 2 in the prostate bed and 1 in the common iliac node chain outside the radiation field. A PSA rise without local or distant disease was observed in 7 (21%) cases. The overall 3-year biochemical progression-free survival rate was 77.3%. Conclusions: Our dose-finding study demonstrated the feasibility of intraoperative radiotherapy in prostate cancer also at the highest administered dose. [Copyright &y& Elsevier]

Objectives: To retrospectively evaluate the functional and oncologic results of 20 prostatic capsule and seminal vesicle-sparing cystectomies. Methods: From June 2002 to January 2006, we performed 360 radical cystectomies, for 20 of which we used a prostatic capsule and seminal vesicle-sparing technique. Patients with Stage T1G3 bladder cancer resistant to intravesical immunotherapy or monofocal T2G3 tumors at transurethral resection of the bladder (TURB) and with preoperative normal sexual function met our inclusion criteria and underwent this procedure. Patients with involvement of the prostatic urethra or multiple tumors were excluded. Prostate-specific antigen measurement, digital rectal examination, and transrectal ultrasonography were performed preoperatively in order to avoid incidental prostate cancer findings. No patient had a preoperative prostate-specific antigen level greater than 4 ng/mL; therefore, no patient underwent preoperative prostate biopsy. The mean patient age was 57.1 years (range 39 to 66). Results: Sexual function recovery and daytime and nighttime continence were reached for all patients. The local recurrence rate in our series was 20% at 2 years of follow-up. Moreover, the distant failure rate was 30%. The 1-year cancer-specific mortality rate was 10% and the 2-year rate was 20%. All disease progressions occurred in patients with Stage T2G3 tumor at TURB. Conclusions: At last follow-up, patients with Stage T1G3 tumor at TURB had not experienced disease progression. Longer follow-up and a larger cohort of patients are necessary to confirm the safety of this procedure in these patients. In our series, the local recurrence and distant metastasis rates were too high compared with those of the patients who underwent radical cystectomy without the sparing technique. Eight of ten patients with muscle invasive bladder cancer at TURB, 8 had disease progression after seminal vesicle-sparing cystectomy. [Copyright &y& Elsevier]