Suprapubic Prostatectomy Research Articles

Observation of post-prostatectomy incontinence :supra-pubic transvesical prostatectomy and transurethral resection of prostate

Objective To evaluate the morbidity of the post-prostatectomy incontinence of supra-pubic transvesical prostatectomy(SPP) and transurethral resection of prostate(TURP). Methods One hundred and thirtyfive patients were divided into two groups. 82 patients underwent SPP and 53 patients underwent TURP. We ob-served the morbidity and the time lasting of post-prostatectomy incontinence, the severity of post-prostatectomy in-continence as evaluated by Stamey incontinence grading system,patients who had more than one week postoperativeincontinence were received urodynamic tests,then we got the information of their incontinence types. Results We found that patients who underwent SPP had higher morbidity, severity and time lasting than those who underwent TURP. SPP group had much more morbidity of stress incontinence than TURP group, but the same morbidity of ur-gent incontinence after operation as the later. Conclusion TURP may be better than SPP in consideration of the post-prostateetomy incontinence. SPP group has more stress incontinence and it may be caused by complete resection of prostate and damnifieation of the mucous membrane of membranous urethra. Key words: Prostatectomy; Transurethral resection of prostate; Prostatic hyperplasia; Urinary incontinence

Lung metastases of low grade phyllodes tumor of the prostate: histopathologic confirmation

Phyllodes tumor of the prostate is a rare neoplasm. We report the clinical, histopathological, and immunohistochemical features of a low grade phyllodes tumor of the prostate with lung metastases. A 68-year-old man presented acute urinary obstruction. Suprapubic prostatectomy was performed, and one month later he developed acute urinary obstruction, shortness of breath and cough. Microscopically, the prostatic tumor showed elongated ducts and cellular stroma. Lung biopsy was composed of stromal cells with enlarged, hyperchromatic nuclei. This case represents a typical low grade prostatic phyllodes tumor to lung. Grading of these neoplasm is not always of value to predict patient prognosis.

A possible role of BDNF in prostate cancer detection

Many studies have demonstrated that both normal and malignant prostate cells respond to a variety of growth factors, while several significant differences were found between normal and tumoural cells. The aim of this study was to focus on the localization and distribution of the immuno-reactivity for neurotrophins (NTs) and neurotrophin receptors (NTRs) in normal, hyperplastic and prostate cancer cells, obtained from 40 subjects. We studied samples obtained from 16 prostate cancer (PC, retropubic radical prostatectomy), 20 benign prostatic hyperplasia (BPH, supra-pubic prostatectomy) and normal peripheral prostate tissue from four fresh male cadavers. Samples were examined via immunohistochemical techniques in order to detect the expression of nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), neurotrophin 3 (NT3) and their own receptors TrkA, p75, TrkB and TrkC. We observed a high expression of BDNF and TrkB in PC and BPH, though no immuno-reactivity was found for p75. Low expression was reported by other NTs and NTRs in the normal peripheral prostate zone, BPH and PC. These data suggest a possible predictive role for NTs and NTRs, especially for BDNF and TrkB, in the diagnosis and/or management of prostate cancer. The absence of p75 expression confirms its supposed role in apoptotic phenomenon.

Clinical Significance of the Expression of Tubulin α and βII in Prostate Cancer

Purpose: This study examined the significance of tubulin α and βII expression in benign prostatic hyperplasia (BPH) and prostate cancer. Materials and Methods: A total 103 cases diagnosed with either BPH or prostate cancer were divided into 4 groups: BPH (n=25), localized prostate cancer (n=41), locally advanced prostate cancer (n=18), metastatic prostate cancer (n=18). The tissues were taken through a transurethral resection of the prostate, suprapubic prostatectomy, prostatic needle biopsy or radical retropubic prostatectomy. The expression was measured by immunohistochemical staining. The degree of expression was graded on a 4-point scale. The data was compared in terms of stage, the serum prostatic specific antigen (PSA) level and Gleason score. The statistical comparisons were made using one-way ANOVA test and a Fisher's exact test. Results: The levels of tubulin α and βII expression were stronger in the patients with prostate cancer than those with BPH (p 0.05). The level of tubulin α expression was stronger in the patients with a Gleason score ≥8 than in those of Gleason score ≤7 (p<0.05), but there was no such difference in tubulin βII expression. The level of tubulin α and βII expression was stronger in the patients with a serum PSA level ≥4ng/ml than in those with the serum PSA level <4ng/ml (p<0.001). Conclusions: The expression of tubulin α and βII may be associated with the development of prostate cancer. These might be used as useful markers for the diagnosis, prognosis and treatment response. (Korean J Urol 2008; 49:709-714) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Complications and Early Postoperative Outcome After Open Prostatectomy in Patients With Benign Prostatic Enlargement: Results of a Prospective Multicenter Study

We prospectively analyzed the complications and immediate postoperative outcome of open prostatectomy for benign prostatic hyperplasia to provide reference data for emerging techniques, such as holmium laser enucleation of the prostate and laparoscopic prostatectomy. A total of 902 patients with a mean +/- 1 SD age of 71.3 +/- 6.8 years were evaluated while undergoing open prostatectomy in Bavaria, Germany from January 1, 2002 to December 31, 2003. We prospectively analyzed 54 parameters concerning preoperative status, surgical details, complications and immediate outcome. Mean operative time was 80.8 +/- 34.2 minutes. Mean prostate size was 96.3 +/- 37.4 ml. Average enucleated tissue was 84.8 +/- 44.0 gm. Incidental carcinoma of the prostate was found in 28 of 902 patients (3.1%) and the mortality rate was 0.2%. The overall complication rate was 17.3%. The most relevant complications were bleeding requiring transfusion in 68 cases (7.5%), urinary tract infection in 46 (5.1%) and surgical revision due to severe bleeding in 33 (3.7%). Patients had an average International Prostate Symptom Score of 20.7 +/- 7.6 preoperatively. Mean urinary peak flow rate increased significantly to 23.1 +/- 10.5 ml per second from a baseline of 10.6 +/- 6.4 ml per second (p <0.0001). Post-void residual volume decreased to 17.5 +/- 34.8 ml from a baseline of 145.1 +/- 152.8 ml (p <0.0001). Open prostatectomy showed a satisfactory early postoperative outcome with a complication rate that was within the expected range compared to that in the recent literature. It represents an important option in the treatment of patients with significant benign enlargement of the prostate for surgeons with no access to modern techniques, such as holmium laser enucleation of the prostate or laparoscopy.

UP-03.75: Comparing sexual function between suprapubic prostatectomy and TURP in patient with BPH

One of the most common causes of LUTS in aging men is BPH. One of the major concepts that is identified by the patients is sexual function post treatment of BPH. In this study we evaluate the influence of suprapubic prostatectomy and TURP on the sexual function. The study was prospective longitudinal.

Suprapubic Prostatectomy With a Novel Catheter

We evaluated the postoperative morbidity and technical complications of a new handmade catheter used for suprapubic prostatectomy. A total of 146 patients with lower urinary tract symptoms who had indications for open prostatectomy were enrolled in the study from January 2003 to August 2004. Of the patients 96 were treated with a novel technique without a urethral catheter but with a special handmade cystostomy catheter, while the other 50 underwent the traditional procedure using cystostomy and a urethral catheter. The same surgical team operated on the 2 groups. Clot retention episodes, hemoglobin decreases, irritative symptoms, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later we followed the patients with symptom score, maximum flow rate and cystoscopic examination. Preoperatively mean International Prostate Symptom Score was 31.6 in each group. Postoperatively none of the patients with the novel catheter complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence. Of the cohorts 94% were satisfied with voiding but 86% of controls were satisfied. There was no report of urinary tract infection or epididymo-orchitis in the cohorts, while we found epididymo-orchitis in 4 controls (8%). Three months after the operation the mean International Prostate Symptom Score was 4.4 (range 1 to 7) and the mean maximum flow rate was 22.6 ml per second (range 14 to 25) in patients with the novel catheter, and 4.2 (range 1 to 7) and 22.5 ml per second (range 15 to 25), respectively, in those with the traditional catheter. At followup there was no bladder neck contracture but 4 patients (4.1%) showed some degree of membranous urethral stricture. We also noted 7 controls (14%) with urethral stricture. Transurethral prostate resection has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia. However, open adenomectomy still has a place. Urethral catheter-free suprapubic prostatectomy can be safely applied with a low postoperative risk of infection, incontinence and stricture formation.

1516: A Prospective Multicenter Study of Complications and Early Postoperative Outcome after Open Suprapubic Prostatectomy

1516: A Prospective Multicenter Study of Complications and Early Postoperative Outcome after Open Suprapubic Prostatectomy

Open Prostatectomy: The Results Of A Series Of 320 Cases In Rural Area

Aim: Suprapubic prostatectomy is frequently performed in areas with poor socioeconomic condition due to insuficient endoscopy equipment. The aim of this retrospective study is to analyse and bring our experience about the open prostatectomy operation Methods: A retrospective study was done on 320 consecutive patients with BPH underwent open prostatectomy operation between January 1996 and December 2002. Analyzed factors were age, complaints, comorbidities (especially cardiac and respiratory), early and late complications and mortalitiy. Results: The total complication rate was 34.6 %. While early complication rate was 20.3 %, late complication rate was 14.3 %. There were no deaths. Early complications were clot retantion (6.6 %), severe intraoperative bleeding (3.2%), wound infection (4.0%) vesicocutaneous leak (4.7%), and reoperation for clot retantion (1.5%). Late complications were urinary tract infection (7.5%), epididymo-orchitis (3.1%), prolonged incontinance (0.9), and bladder neck or urethral stricture (2.2%). Conclusion: Our study demonstrated that open prostatectomy for benign prostatic hyperplasia (BPH) is an acceptable option with a high degree of safety and efficacy in areas where the TUR-P equipment is lacking or this operation is technically impossible.

Reconstrucción tridimensional in vitro de mucosa vesical humana

ObjetiveThe purpose of this study is to apply the in vitro keratinocyte culture techniques and the tissue engineering principles to human urothelium, to reconstruct an in vitro three-dimensional human bladder mucosa, suitable for grafting Material and MethodsBiopsy specimens of human bladder mucosa were obtained from patients undergoing suprapubic prostatectomy, in vitro cultured and finally, an immunohistochemical study was made ResultsA three-dimensional in vitro tissue was obtained, composed of a bio-artificial submucosa (fibrin gel and fibroblast) where the uroepithelial cells were seeding. We used a biodegradable polyglycolic acid mesh to facilitate the tissue manipulation and implantation. An immature epithelium was obtained with a weak immunostaining to cytokeratins. The immunohistochemical study could not demonstrate the development of basement membrane ConclusionsIn vitro keratinocyte culture techniques could be applied to other epithelial tissues like the urothelium. We obtained a three-dimensional in vitro tissue suitable for grafting in a relatively short time, which needs the matrix interactions in order to mature

Hæmorrhage and post-operative obstruction in suprapubic prostatectomy : And an open operation for their prevention

Hæmorrhage and post-operative obstruction in suprapubic prostatectomy : And an open operation for their prevention

Juvenile prostatic hyperplasia

Benign prostatic hyperplasia is common in aging men, but rare in childhood. We report a case of juvenile prostatic hyperplasia in a 10-year-old boy, who visited our clinic for hematuria and voiding symptoms. Radiologic studies revealed a huge prostate protruding into the bladder. The prostate was 33 g. The prostate biopsy showed no evidence of cancer. At 13 years of age, he was seen again because of general weakness, fever, and voiding difficulty. Bilateral hydroureteronephrosis was found on radiologic studies, and his serum creatinine was elevated. The prostate was 55 g. Suprapubic prostatectomy was performed.

Are indications for prostatectomy in octogenarians the same as for younger men?

Prostatectomy for benign hypertrophy of the prostate is usually performed to alleviate lower urinary tract symptoms (LUTS). We assessed indications for and risks of prostatectomy in men 80 years of age and compared them to those for younger men in order to determine whether indications for prostatectomy in octogenarians are different than these for younger men. Medical records of 171 men comprised of 84 patients >80 years of age (mean 84.4) and 87 patients <65 years of age (mean 60.6) who underwent prostatectomy for benign prostate hypertrophy were reviewed. Data regarding indications for surgery, American Society of Anesthesiologists system grade, anesthesia and surgery performed, duration of hospitalization and intrahospital postoperative complications were obtained. The respective indications for surgery in the very elderly and younger patients were: urinary retention with indwelling catheter in 46 (55%) and 34 (39%) (p < 0.04), LUTS in 32 (38%) and 52 (59%) (p < 0.005), and gross hematuria in 6 (7%) and 1 (1.2%). Transurethral prostatectomy was performed in 47 elderly patients (56%) and in 30 young patients (34.5%). The other patients in each group underwent open (suprapubic prostatectomy) surgery. The overall complication rate was significantly higher in the elderly group (39% vs 22%, p < 0.05), with major complications occurring only in this group. Indications for surgery were different for octogenarians than for younger men. Morbidity and mortality rates were significantly higher among the elderly men. Age appears to be an independent risk factor for complications associated with prostatectomy.

Villous Adenoma of the Urachus: A Case with Prostate Specific Antigen Immunoreactivity

We report a case of a villous adenoma of the urachus discovered incidentally during suprapubic prostatectomy, and discuss a novel immunohistochemical finding that could be diagnostically useful. CASE REPORT A 68-year-old man underwent simultaneous right ureterolithotomy and suprapubic prostatectomy because of hydronephrosis (due t oa2c mcalculus in the ipsilateral lower ureter) and acute urinary retention due to prostatic enlargement, respectively. During prostatectomy an ovoid cystic mass (not diagnosed before surgery by imaging techniques) was noted in the bladder dome without involvement of the adjacent structures. Partial cystectomy with excision of the mass was performed. Postoperative recovery was uneventful. No recurrence of the tumor was noted at 19 months following excision. Gross examination of the specimen showed a mucus filled cystic structure 8 cm in diameter associated with a portion of bladder wall 5 cm in diameter. The lining of the cyst demonstrated an exophytic papillary area 0.8 cm in diameter, which was clearly separated from the surrounding epithelium. Histological examination revealed a cyst lined by transitional epithelium containing a neoplasm with villoglandular architecture (fig. 1, A). The neoplastic cells displayed slight nuclear stratification and crowding, mild nuclear hyperchromatism and occasional prominent nucleoli, while the tumor cell cytoplasm contained acidic mucin (fig. 1, B). Mitotic figures were rare. In the adjacent smooth muscle there were urachal remnants. Tumor invasion was not observed. The pathological diagnosis was villous adenoma that had developed in a urachal cyst. The neoplastic cells exhibited immunoreactivity for cytokeratin 20 and carcinoembryonic antigen. In addition, there was prostatic specific antigen (PSA) immunostaining in the tumor cells and the epithelium of the urachal remnants (fig. 2). Preoperatively, serum PSA was within normal range, while the prostatic specimen showed benign nodular hyperplasia.

Acquired bladder diverticula can mimic obstructive extrabiliary jaundice

A rare case that relates benign prostatic hyperplasia-associated bladder diverticula and obstructive uropathy to extrabiliary obstructive jaundice in an older patient is presented. Immediate decompression of the bladder allowed for prompt restoration of the biliary drainage and normalization of the creatinine within a few days. A hepatobiliary etiology was discarded through prompt radiologic and serologic testing along with computed tomography-guided liver biopsy. Long-term management included open suprapubic prostatectomy and diverticulectomy. This unusual case expands the amount of sound anatomic and pathophysiologic links between urinary and extraurinary manifestations.

Modified Denis technique: a simple solution for maximal hemostasis in suprapubic prostatectomy

Objectives To describe our experience with a modified Denis technique for hemostasis in suprapubic prostatectomy. Methods We reviewed the charts of 78 patients who underwent suprapubic prostatectomy using a modified Denis technique between September 1996 and June 2001. After adenomectomy, we performed a bladder neck removable partition purse-string suture, and the prostatic fossa was drained. Patients were followed up for hemorrhagic complications and bladder neck strictures for 12 months. Results The mean intraoperative hemorrhage amount was 264 mL (range 160 to 510). The postoperative irrigating fluid volume was 2000 mL (range 500 to 4500), and the bladder irrigation duration was 24 hours in 70 patients (89.8%) and 48 hours in 8 patients (10.2%). Postoperative hemorrhage, measured by the prostatic fossa drain, was 0 mL in 48 patients and had a mean value of 55 mL (range 10 to 90) in 30 patients. No hemorrhagic complication was noted. None of our patients had transfusion, bladder clot formation, or late hemorrhage. One case (1.3%) of bladder neck stricture developed. Conclusions This modified Denis technique is very effective and easy to perform and to learn. It has solved all our hemorrhagic problems in suprapubic prostatectomy.

Hémostase dans l’adénomectomie prostatique transvésicale selon la technique de Denis modifiée. À propos de 20 cas

The authors present modified Denis’s technique for hemostasis in 20 suprapubic prostatectomy. The technique is based on the separation between the blader and the prostatic fossa with a temporary purse-string suture around the bladder neck. The vacuum of the prostatic fossa leads to the retraction and hemostatis. This technique is very effective on intra and post operative hemorrhage, so economy of irrigating fluid; then easier post operative care.

Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study.

To evaluate urinary symptoms, sexual dysfunction and quality of life in patients with benign prostatic hypertrophy (BPH) before and after open prostatectomy, using the International Prostate Symptom Score (IPSS), the International Continence Society (ICS)-"BPH" (ICS-male, ICS-sex and ICS-QoL) and International Index of Erectile Function (IIEF) questionnaires. Sixty men with BPH (mean age 68 years) underwent a digital rectal examination, transurethral ultrasonography, measurement of total prostatic specific antigen serum level and uroflowmetry. Their urinary symptoms, sexual function and quality of life were fully evaluated using the IPSS, ICS-"BPH" and IIEF before and 6 months after suprapubic prostatectomy. The body mass index (BMI) was also calculated for each patient. Univariate analysis was used to examine the relationship between symptom scores and age, tobacco use, alcohol intake and BMI. In a univariate analysis, age was the most important prognostic factor for both urinary and sexual symptoms. Prostatectomy resulted in a significant improvement in obstructive (mean 9.68 to 3.38) and irritative symptom (6.70 to 3.06), and quality-of-life scores (3.41 to 1.34). ICS-male scores were both significantly decreased, the mean voiding score from 13.72 to 10.28 and the incontinence score from 10.43 to 7.81. There was also a significant decrease in the ICS-QoL symptom score (from 9.20 to 7.27). Comparative results between IIEF and ICS-sex showed no improvement in sexual scores after open surgery, but there was a significant increase in sexual desire and overall satisfaction (both P = 0.035). The combined use of the IPSS, ICS-"BPH" and IIEF allows an evaluation of the relationship between age, prostatic symptoms and sexual dysfunction. Age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity. Suprapubic prostatectomy resolves obstructive symptoms, and maintains sexual desire, overall sexual satisfaction and an improvement in quality of life. However, irritative symptoms, erection, orgasm and sexual intercourse satisfaction are not significantly altered.

Laparoscopic Prostatectomy With Vascular Control for Benign Prostatic Hyperplasia

No AccessJournal of UrologyCLINICAL UROLOGY: Case Reports1 Jun 2002Laparoscopic Prostatectomy With Vascular Control for Benign Prostatic Hyperplasia MIRANDOLINO BATISTA MARIANO, TULIO MEYER GRAZIOTTIN, and MARCOS VINICIUS TEFILLI MIRANDOLINO BATISTA MARIANOMIRANDOLINO BATISTA MARIANO More articles by this author , TULIO MEYER GRAZIOTTINTULIO MEYER GRAZIOTTIN More articles by this author , and MARCOS VINICIUS TEFILLIMARCOS VINICIUS TEFILLI More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)65025-2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Laparoscopic Prostatectomy With Vascular Control for Benign Prostatic Hyperplasia." The Journal of Urology, 167(6), pp. 2528–2529 References 1 : Retropubic and suprapubic prostatectomy. In: . Philadelphia: W. B. Saunders Co.1998: 1529. chapt. 50. Google Scholar 2 : Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol2001; 165: 459. Link, Google Scholar 3 : Laparoscopic radical prostatectomy: preliminary results. Urology2000; 55: 630. Google Scholar From the Department of Urology, Hospital Mãe-de-Deus, Porto Alegre, Brazil© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byAbou Zeinab M, Beksac A, Corse T, Talamini S, Morgantini L, Kaviani A, Ferguson E, Eltemamy M, Crivellaro S, Ahmed M, Stifelman M and Kaouk J (2022) The Multi-Institutional Experience in Single-Port Robotic Transvesical Simple Prostatectomy for Benign Prostatic Hyperplasia ManagementJournal of Urology, VOL. 208, NO. 2, (369-378), Online publication date: 1-Aug-2022.Kaplan S (2018) Re: Preperitoneal Single-Port Transvesical Enucleation of the Prostate (STEP) for Large-Volume BPH: One-Year Follow-up of Qmax, IPSS, and QoLJournal of Urology, VOL. 189, NO. 5, (1822-1823), Online publication date: 1-May-2013.Chlosta P, Varkarakis I, Drewa T, Dobruch J, Jaskulski J, Antoniewicz A and Borówka A (2018) Extraperitoneal Laparoscopic Millin Prostatectomy Using Finger EnucleationJournal of Urology, VOL. 186, NO. 3, (873-876), Online publication date: 1-Sep-2011.Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M and Fagin R (2018) Robotic Simple ProstatectomyJournal of Urology, VOL. 179, NO. 2, (513-515), Online publication date: 1-Feb-2008.Baumert H, Ballaro A, Dugardin F and Kaisary A (2018) Laparoscopic Versus Open Simple Prostatectomy: A Comparative StudyJournal of Urology, VOL. 175, NO. 5, (1691-1694), Online publication date: 1-May-2006.SOTELO R, SPALIVIERO M, GARCIA-SEGUI A, HASAN W, NOVOA J, DESAI M, KAOUK J and GILL I (2018) LAPAROSCOPIC RETROPUBIC SIMPLE PROSTATECTOMYJournal of Urology, VOL. 173, NO. 3, (757-760), Online publication date: 1-Mar-2005. Volume 167Issue 6June 2002Page: 2528-2529 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsprostatectomytransurethral resection of prostatelaparoscopyprostatic hyperplasiaMetricsAuthor Information MIRANDOLINO BATISTA MARIANO More articles by this author TULIO MEYER GRAZIOTTIN More articles by this author MARCOS VINICIUS TEFILLI More articles by this author Expand All Advertisement PDF downloadLoading ...

Transurethral resection of prostate perioperative hypotension

OBJECTIVE: To identify the factors to transurethral resection of prostate (TURP) perioperative hypotension. METHODS: The study group included 130 patients undergoing TURP. The control group included 50 patients who had suprapubic prostatectomy. Absorption of irrigation fluid was measured by determining the serum gentamycin level. Blood loss of PURP patients was calculated as the product of the irrigation fluid volume and hemoglobin concentration (determined with a photometer) divided by the preopreative blood hemoglobin concentration. Body temperature was recorded using a rectal probe. Serum electrolytes were determined pre-and postop. RESULTS: The blood loss in study group (380.2+/-98.3)ml was significantly less than in the control group (460.1+/-52.5)ml, P<0.05. However, the incidence of hypotension was significantly higher than the control group 28%, 8%), P<0.01. Factors associated with TURP hypotension included volume of irrigation fluid absorption, blood loss, reduction in core temperature, decrease of serum sodium, operating time, prostate weight and volume and history of cardiovascular disease. After Logistic regression analysis, the most significant factors were excessive absorption of irrigation fluid and rapid central cooling. CONCLUSION: In our study TURP hypotension most closely correlated with volume of irrigation fluid absorbed and reduction in core temperature.