Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

To investigate the role of bile acids (BAs) in the pathogenesis of diet-induced nonalcoholic steatohepatitis (NASH), we fed a “Western-style diet” [high fructose, high fat (HFF)] enriched with fructose, cholesterol, and saturated fat for 10 wk to juvenile Iberian pigs. We also supplemented probiotics with in vitro BA deconjugating activity to evaluate their potential therapeutic effect in NASH. Liver lipid and function, cytokines, and hormones were analyzed using commercially available kits. Metabolites, BAs, and fatty acids were measured by liquid chromatography-mass spectrometry. Histology and gene and protein expression analyses were performed using standard protocols. HFF-fed pigs developed NASH, cholestasis, and impaired enterohepatic Farnesoid-X receptor (FXR)-fibroblast growth factor 19 (FGF19) signaling in the absence of obesity and insulin resistance. Choline depletion in HFF livers was associated with decreased lipoprotein and cholesterol in serum and an increase of choline-containing phospholipids in colon contents and trimethylamine- N-oxide in the liver. Additionally, gut dysbiosis and hyperplasia increased with the severity of NASH, and were correlated with increased colonic levels of choline metabolites and secondary BAs. Supplementation of probiotics in the HFF diet enhanced NASH, inhibited hepatic autophagy, increased excretion of taurine and choline, and decreased gut microbial diversity. In conclusion, dysregulation of BA homeostasis was associated with injury and choline depletion in the liver, as well as increased biliary secretion, gut metabolism and excretion of choline-based phospholipids. Choline depletion limited lipoprotein synthesis, resulting in hepatic steatosis, whereas secondary BAs and choline-containing phospholipids in colon may have promoted dysbiosis, hyperplasia, and trimethylamine synthesis, causing further damage to the liver. NEW & NOTEWORTHY Impaired Farnesoid-X receptor (FXR)-fibroblast growth factor 19 (FGF19) signaling and cholestasis has been described in nonalcoholic fatty liver disease (NAFLD) patients. However, therapeutic interventions with FXR agonists have produced contradictory results. In a swine model of pediatric nonalcoholic steatohepatitis (NASH), we show that the uncoupling of intestinal FXR-FGF19 signaling and a decrease in FGF19 levels are associated with a choline-deficient phenotype of NASH and increased choline excretion in the gut, with the subsequent dysbiosis, colonic hyperplasia, and accumulation of trimethylamine- N-oxide in the liver.

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Lymphangiomas are benign tumours of the lymphatic system, and there are several reported cases of scrotal lymphangioma in the literature to date. We report a rare case of multilocular cutaneous lymphangiomatosis treated with surgical excision (total scrotectomy and reconstruction using split-thickness skin grafts with vacuum-assisted closure dressing). Case reportA 39-year-old healthy male presented with a 20-year history of recurrent, complicated scrotal lymphangiomatosis. The lesions had previously been treated with local excision and cauterization, laser ablation and cryotherapy, but the lymphangiomas recurred quicker and denser in number following each treatment. The patient was referred to our urology clinic in 2007 with complaints of perineal pain. Physical examination demonstrated the scrotum itself was nodular and thickened with innumerable cutaneous lymphangiomas, with complete sparing of the penile skin. Following discussion with the patient, a continued conservative approach was initially exercised with antibiotic treatment and suppression of chronic scrotal cellulitis without surgical consideration of the lesions themselves. Despite this, the patient continued to suffer from recurrent infections of spontaneously ruptured lesions. Given the ineffectiveness of conservative therapy, the notable confinement of lymphangiomas to the scrotal skin ( Fig. 1), and the ongoing psychological impact of the condition on the patient, a decision was made to escalate to surgical management consisting of total scrotectomy with reconstruction.The patient was brought to the operating room, and following induction of general anesthesia, a "W" incision was made along the baseline such that the entire scrotum was incorporated while leaving skin 1 cm above the anus intact, thus forming a shape resembling the letter "W" (Fig. 2). The scrotum, including the epithelium, dermis, and superficial subcutaneous tissues, were dissected off using a combination of #15 blade and the Metzenbaum scissors (Fig. 2). While the scrotectomy was being performed, the split-thickness graft was harvested from a shaved area on the right donor thigh. The Zimmer dermatome (Zimmer Inc., United Kingdom) set to 12/1000 of an inch was used to harvest the skin graft, which was then meshed in a 1.5:1 fashion, and used to cover the area of defect. The borders of the graft were stapled in place, and then further quilted into place using 4-0 Vicryl sutures (Fig. 3). A vacuum-assisted closure (VAC) sponge was conformed to the skin-grafted area and reinforced with additional OpSite (Smith & Nephew Healthcare, United Kingdom) dressings.At one-month follow-up, there were a few small areas of delayed healing, overall good take of the graft, and no recurrence of scrotal lymphangiomatosis (Fig. 4). The shaft of the penis appeared to remain well-vascularized. The patient reported little pain, and was able to have normal erections with no chordee or deviation. The six-month follow-up showed almost complete healing, and no recurrence was observed (Fig. 5). Dis...

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Objective. To determine the clinical factors of the enhanced risk of malignancy in patients, having categories of cytological conclusions III (AUS/FLUS) and IV (FN/SFN). Маterials and methods. There were 11 621 patients examined with cytological investigation of thyroidal nodes under ultrasonographic control. Cytological conclusions of category ІІІ (AUS/FLUS) have characterized 621 nodes, while conclusions of category IV (FN/SFN) - 1215 nodes. There were operated 150 patients, owing cytological conclusions of category III, 436 patients - with cytological conclusions of category IV, and 11 patients, having categories of cytological conclusions III and IV. Results. Papillary and follicular carcinomas were revealed in 36% patients, suffering thyroidal nodes of the Bethesda III category, what is trustworthily more frequently (р < 0.01), than in the patients, suffering thyroidal nodes of the Bethesda category IV (25.1%). There were revealed such factors of risk for malignant properties in patients, suffering thyroidal nodes with the Bethesda category III, as: the node size 2 сm and less, its hypoechogeneicity, uneven borders, irregular form, and presence of hyperechogenic foci (р < 0.01). Cystic degeneration of a node constitutes the sign of its benign origin (р < 0.01). Conclusion. High risk of malignant changes (36%) in thyroidal nodes, in accordance to cytological conclusion of the Bethesda category III revealed, trusts the need for enhanced oncological suspicion and conduction of surgical treatment. Тhe additional factors of malignant changes must be taking into account as well, such as the node size 2 сm and less, its hypoechogeneicity, uneven borders, irregular form, and presence of hyperechogenic foci.

Carcinoma of parathyroid gland as a part of polyglandular primary hyperparathyreosis