povidone-iodine and Urinary-Bladder-Neoplasms

We present a case of asystole due to anaphylactoid reaction after vaginal disinfection with povidone iodine under epidural anesthesia combined with general anesthesia. A 71-year-old woman was scheduled to undergo total cystectomy due to vesical cancer, invading into the wall of the vagina. After induction of anesthesia, epidural injection with 10 ml of 1% lidocaine and cleansing the vagina with povidone iodine solution were done at the same time. Shortly thereafter, sudden hypotension and bradycardia and asystole occurred. Multiple doses of epinephrine, chest compression, transcutaneous pacing and defibrillation were required to restore her spontaneous circulation. The surgery was cancelled. She stayed a night at the intensive care unit, and was discharged without any neurological complications the next day. The serum concentration of histamine increased to 7.0 microg x l(-1), but that of tryptase was within normal ranges when spontaneous circulation returned. The serum concentration of total iodine increased to 57.9 microg x dl(-1), which did not reach the toxic level. These results suggest that the circulatory collapse was probably caused by anaphylactoid reaction to povidone iodine. Epidural anesthesia may have worsened the circulatory collapse.

Topics: Aged; Anaphylaxis; Anesthesia, Epidural; Anesthesia, General; Anti-Infective Agents, Local; Cystectomy; Female; Heart Arrest; Humans; Povidone-Iodine; Urinary Bladder Neoplasms

Peritoneal macrophages play a critical role in maintaining local host resistance to infection and malignancy through the secretion of tumor necrosis factor-alpha (TNF-alpha). We hypothesized that attenuated TNF-alpha secretion, as a result of CO(2) pneumoperitoneum, could alter local immune surveillance, thereby contributing to the development of carcinomatosis and incisional metastasis. We further sought to determine if port-site metastasis could be prevented with prophylactic irrigants.. C57BL/6 mice (n = 50) and the syngenic murine bladder tumor (MBT-2) cell line were used. Experiment 1: Mice were subjected to either CO(2) pneumoperitoneum at 6 mm Hg (n = 10) or a 3-cm midline incision (n = 10). Peritoneal macrophages (1 x 10(6)/animal) were collected and subjected to lipopolysaccharide challenge. TNF-alpha levels were quantified using the Quantikine Mouse TNF-alpha/TNFSF1A Immunoassay. Experiment 2: Peritoneal and port-site metastasis were evaluated 1 week after 1 x 10(6) MBT-2 cells/animal were spilled in an open group (n = 5) and through 5-mm trocars of a pneumoperitoneal group (n = 5). Experiment 3: 1 x 10(6) MBT-2 cells/animal were spilled intraperitoneally through 5-mm trocars of four groups (n = 20). Port sites in each group were then irrigated with either sterile water, mitomycin C (1.0 mg/mL), betadine (10%), or heparin (1000 U/mL). At 1 week, incisional sites were evaluated for gross and microscopic metastasis. In each experiment, Student t-test was used to quantify statistical differences.. Peritoneal macrophage TNF-alpha secretion was significantly inhibited in mice subjected to CO(2) pneumoperitoneum v control at 10 and 20 minutes (P = 0.015, P = 0.001, respectively). When 1 x 10(6) MBT-2 cells were spilled, a significantly higher average tumor burden developed in animals subjected to CO(2) pneumoperitoneum than in controls at 1 week (9.2 gm v 3.8 g, P = 0.002). All irrigants prevented the development of port-site metastasis, yet sterile water did so without toxic effect.. In a syngenic murine model, CO(2) pneumoperitoneum causes inhibition of peritoneal macrophage TNF-alpha secretion. Heavier intraperitoneal and incisional metastasis develops in C57BL/6 mice subjected to CO(2) pneumoperitoneum and a tumor challenge with 1 x 10(6) MBT-2 tumor cells compared with open controls. Inhibition of peritoneal macrophage TNF-alpha secretion may be considered an adverse event contributing to the development of transitional-cell carcinoma (TCC) port-site metastasis, especially if surgical oncologic principles are violated. Irrigating trocar sites and the peritoneal cavity with sterile water at the conclusion of laparoscopic nephroureterectomy and laparoscopic radical cystectomy may offer a safe prophylactic strategy to prevent this unfavorable event. Our murine model presents a novel avenue for the development of adjunct immunomodulatory therapies to perhaps further reduce oncologic risks during laparoscopic management of TCC.

Topics: Animals; Anti-Infective Agents, Local; Antibiotics, Antineoplastic; Carbon Dioxide; Carcinoma, Transitional Cell; Cell Line, Tumor; Female; Heparin; In Vitro Techniques; Laparoscopy; Macrophages, Peritoneal; Mice; Mice, Inbred C57BL; Mitomycin; Neoplasm Seeding; Pneumoperitoneum, Artificial; Povidone-Iodine; Therapeutic Irrigation; Tumor Necrosis Factor-alpha; Urinary Bladder Neoplasms