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We report on the annual variation of quiet-time suprathermal ion composition for C through Fe using Advanced Composition Explorer (ACE)/Ultra-Low Energy Isotope Spectrometer data over the energy range 0.3–1.28 MeV nuc−1 from 1998 through 2019, covering solar cycle 23's rising phase through Solar Cycle 24's declining phase. Our findings are: (1) quiet-time suprathermal abundances resemble CIR-associated particles during solar minima; (2) quiet-time suprathermals are M/Q fractionated in a manner that is consistent with M/Q fractionation in large gradual solar energetic particle events (GSEP) during solar maxima; and (3) variability within the quiet-time suprathermal pool increases as a function of M/Q and is consistent with the analogous variability in GSEP events. From these observations, we infer that quiet-time suprathermal ions are remnants of CIRs in solar minima and GSEP events in solar maxima. Coincident with these results, we also unexpectedly show that S behaves like a low FIP ion in the suprathermal regime, and is therefore drawn from low FIP solar sources. [ABSTRACT FROM AUTHOR]

Objective: To present 6‐month safety and effectiveness data from a multicentre prospective study of aquablation in men with lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) with prostate volumes between 80 and 150 mL. Methods: Between September and December 2017, 101 men with LUTSattributable to BPHwere prospectively enrolled at 16 centres in Canada and the USA. Results: The mean prostate volume was 107 mL. The mean length of hospital stay after the aquablation procedure was 1.6 days (range: same day to 6 days). The primary safety endpoint (Clavien–Dindo grade 2 or higher or any grade 1 event resulting in persistent disability) at 3 months occurred in 45.5% of men, which met the study design goal of < 65% (P < 0.001). At 6 months, 22% of the patients had experienced a Clavien–Dindo grade 2, 14% a grade 3 and 5% a grade 4 adverse event. Bleeding complications requiring intervention and/or transfusion were recorded in eight patients prior to discharge and in six patients after discharge. The mean International Prostate Symptom Score improved from 23.2 ± 6.3 at baseline to 6.7 ± 5.1 at 3 months, meeting the study's primary efficacy endpoint goal (P < 0.001). The maximum urinary flow rate increased from 8.7 to 18.8 mL/s (P < 0.001) and post‐void residual urine volume decreased from 131 at baseline to 47 at 6 months (P < 0.0001). At 6 months, prostate‐specific antigen concentration reduced from 7.1 ± 5.9 ng/mL at baseline to 4.0 ± 3.9 ng/mL, a 44% reduction. Conclusions: Aquablation is safe and effective in treating men with larger prostates (80–150 mL), without significant increase in procedure or resection time. [ABSTRACT FROM AUTHOR]

Objectives: To present early safety and feasibility data from a multicentre prospective study (WATER II) of aquablation in the treatment of symptomatic men with large‐volume benign prostatic hyperplasia (BPH). Methods: Between September and December 2017, 101 men with moderate‐to‐severe BPH symptoms and prostate volume of 80–150 mL underwent aquablation in a prospective multicentre international clinical trial. Baseline demographics and standardized postoperative management variables were carefully recorded in a central independently monitored database. Surgeons answered analogue scale questionnaires on intra‐operative technical factors and postoperative management. Adverse events up to 1 month were adjudicated by an independent clinical events committee. Results: The mean (range) prostate volume was 107 (80–150) mL. The mean (range) operating time was 37 (15–97) min and aquablation resection time was 8 (3–15) min. Adequate adenoma resection was achieved with a single pass in 34 patients and with additional passes in 67 patients (mean 1.8 treatment passes), all in a single operating session. Haemostasis was achieved using either a Foley balloon catheter placed in the bladder under traction (n = 98, mean duration 18 h) or direct tamponade using a balloon inflated in the prostate fossa (n = 3, mean duration 15 h). No patient required electrocautery for haemostasis at the time of the primary procedure. The mean length of stay after the procedure was 1.6 days (range same day to 6 days). The Clavien–Dindo grade ≥2 event rate observed at 1 month was 29.7%. Bleeding complications were recorded in 10 patients (9.9%) during the index procedure hospitalization prior to discharge, and included six (5.9%) peri‐operative transfusions. Conclusions: Aquablation is feasible and safe in treating men with men with large prostates (80–150 mL). The 6‐month efficacy data are being accrued and will be presented in future publications (ClinicalTrials.gov number, NCT03123250). [ABSTRACT FROM AUTHOR]

Objective: To report procedure process improvements and confirm the preserved safety and short-term effectiveness of a secondgeneration Aquablation device for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) in 47 consecutive patients at a single institution. Patients and Methods: Aquablation was performed in 47 patients with symptomatic BPH at a single institution. Baseline, peri-operative and 3-month urinary function data were collected. Results: The mean (range) patient age was 66 (50-79) years, and transrectal ultrasonography-measured prostate volume was 48 (20-118) mL. A median lobe was present in 25 patients (53%) and eight patients had catheter-dependent urinary retention. The mean (range) total procedure time was 35 (13-128) min and the tissue resection time was 4 (1-10) min. Five Clavien-Dindo grade I/II and five Clavien-Dindo grade III complications were recorded in eight patients. The mean (range) hospital stay was 3.1 (1-8) days and the mean (range) duration of urethral catheterization was 1.9 (1-11) days. The mean International Prostate Symptom Score (IPSS) decreased from 24.4 at baseline to 5 at 3 months; IPSS quality-of-life score decreased from 4.5 to 0.3 points; peak urinary flow rate increased from 7.1 to 16.5 mL/s and post-void residual urine volume decreased from 119 to 43 mL (all P < 0.01). Conclusions: This study confirmed procedure process improvements resulting from system enhancements, with preservation of safety and effectiveness during use of a second-generation device for the treatment of LUTS attibutable to BPH in the largest single-institution study conducted to date. [ABSTRACT FROM AUTHOR]

Solar energetic particles, or SEPs, from suprathermal (few keV) up to relativistic ( $$\sim $$ few GeV) energies are accelerated near the Sun in at least two ways: (1) by magnetic reconnection-driven processes during solar flares resulting in impulsive SEPs, and (2) at fast coronal-mass-ejection-driven shock waves that produce large gradual SEP events. Large gradual SEP events are of particular interest because the accompanying high-energy ( $${>}10$$ s MeV) protons pose serious radiation threats to human explorers living and working beyond low-Earth orbit and to technological assets such as communications and scientific satellites in space. However, a complete understanding of these large SEP events has eluded us primarily because their properties, as observed in Earth orbit, are smeared due to mixing and contributions from many important physical effects. This paper provides a comprehensive review of the current state of knowledge of these important phenomena, and summarizes some of the key questions that will be addressed by two upcoming missions-NASA's Solar Probe Plus and ESA's Solar Orbiter. Both of these missions are designed to directly and repeatedly sample the near-Sun environments where interplanetary scattering and transport effects are significantly reduced, allowing us to discriminate between different acceleration sites and mechanisms and to isolate the contributions of numerous physical processes occurring during large SEP events. [ABSTRACT FROM AUTHOR]

Solar energetic particles, or SEPs, from suprathermal (few keV) up to relativistic (~few GeV) energies are accelerated near the Sun in at least two ways: (1) by magnetic reconnection-driven processes during solar flares resulting in impulsive SEPs, and (2) at fast coronal-mass-ejection-driven shock waves that produce large gradual SEP events. Large gradual SEP events are of particular interest because the accompanying high-energy (>10s MeV) protons pose serious radiation threats to human explorers living and working beyond low-Earth orbit and to technological assets such as communications and scientific satellites in space. However, a complete understanding of these large SEP events has eluded us primarily because their properties, as observed in Earth orbit, are smeared due to mixing and contributions from many important physical effects. This paper provides a comprehensive review of the current state of knowledge of these important phenomena, and summarizes some of the key questions that will be addressed by two upcoming missions--NASA's Solar Probe Plus and ESA's Solar Orbiter. Both of these missions are designed to directly and repeatedly sample the near-Sun environments where interplanetary scattering and transport effects are significantly reduced, allowing us to discriminate between different acceleration sites and mechanisms and to isolate the contributions of numerous physical processes occurring during large SEP events. [ABSTRACT FROM AUTHOR]

The article discusses the advances made in therapeutic flexible endoscopy technology. It states that the flexible ureterorenoscopy is popularly used in the treatment of calculous disease and other diagnostic and therapeutic indications. Technological advancements such as a robotic platform for laparoscopic surgery, robotic external manipulator, and actively manipulated robotic catheters are discussed.

Objectives: To present time-efficiency data during our initial experience with intracorporeal urinary diversion and technical tips that may shorten operative time early in the learning curve. Patients and Methods: Data were analyzed in the initial 37 consecutive patients undergoing robotic radical cystectomy and intracorporeal urinary diversion in whom detailed stepwise operative time data were available. Median age was 65 years and median body mass index was 27. Neoadjuvant chemotherapy was administered in 6 patients and 11 patients had clinical evidence of T3 or lymph node-positive disease. Each component of the operation was subdivided into specific steps and operative time for each step was prospectively recorded. Peri-operative and follow-up data up to 90 days and final pathological data were recorded. Results: All procedures were completed intracorporeally and robotically without need for conversion to open surgery or extracorporeal diversion. Median total operative time was 387 vs 386 minutes ( p=0.2) and median total console time was 361 vs 295 minutes ( p<0.007) for orthotopic neobladder and ileal conduit, respectively. Median time for radical cystectomy was 77 minutes, extended pelvic lymph node dissection was 63 minutes, and diversion was 111 minutes (ileal conduit 92 minutes and orthotopic neobladder 124 minutes). Median estimated blood loss was 250 mL, and median hospital stay was 9 days. High grade (Clavien grade 3-5) complications at 30 and 90 days follow-up were recorded in 6 (16%) and 9 (24%) patients, respectively. Over a median follow-up of 16 months, 12 (32%) patients experienced disease recurrence and 9 (24%) died from bladder cancer. These correspond to 1-year recurrence-free and overall survival of 64% and 70%, respectively. Conclusions: Intracorporeal urinary diversion following robotic radical cystectomy can be safely performed and reproducible in a time-efficient manner even during the early learning curve. [ABSTRACT FROM AUTHOR]

Background Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery. Objective Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN. Design, setting, and participants A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n = 58) or main artery clamping (group 2, n = 63). Intervention Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia. Outcome measurements and statistical analysis Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used. Results and limitations All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6 cm, p = 0.004), more commonly hilar (24% vs 6%, p = 0.009), and more complex (PADUA 10 vs 8, p = 0.009). Group 1 patients had longer median operative time ( p < 0.001) and transfusion rates (24% vs 6%, p < 0.01) but similar estimated blood loss (200 vs 150 ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p = 0.01) and at last follow-up (11% vs 17%, p = 0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p = 0.07) despite larger tumor size and volume (19 vs 8 ml, p = 0.002). Main limitations are the retrospective study design, small cohort, and short follow-up. Conclusions Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies. Patient summary Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques. [ABSTRACT FROM AUTHOR]

Abstract: Background: With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND). Objective: Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC. Design, setting, and participants: From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n =10) or aortic bifurcation (n =5) in 15 patients undergoing robotic RC (n =4) or laparoscopic RC (n =11) at two institutions. Surgical procedure: We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique. Measurements: Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n =5) and ileal conduit (n =10), were performed extracorporeally. Results and limitations: All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7h, estimated blood loss was 500ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15–78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients. Conclusions: High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer. [Copyright &y& Elsevier]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The exact incidence of splenic injury during laparoscopic urologic procedures is not known; however, it is an uncommon occurrence. Also, the optimal treatment algorithm is not well delineated and the efficacy of successfully treating minor injuries to the spleen without resorting to splenectomy is not well described in the urologic literature. This study outlines the rate of splenic injury during a variety of laparoscopic urologic procedures and we outline a treatment algorithm that has been successfully employed in the management of these patients, which in all cases, did not lead to splenectomy. An important point is also that multiple adjunctive hemostatic measures should be used when a splenic injury is recognized and that a thorough search should ensue when suspicion of an occult splenic injury exists, as an unrecognized splenic injury may lead to severe post operative haemorrhagic complications. OBJECTIVE • To evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort. PATIENTS AND METHODS • All patients undergoing laparoscopic urological upper tract procedures at two institutions between January 2001 and April 2006 and January 2000 and December 2008, respectively, were retrospectively examined for complications. • From these patients, those with intraoperative splenic injuries were selected and examined. • Possible factors predisposing patients to splenic injury were evaluated and the management plan for each patient was analysed to identify optimal treatment efficacy. RESULTS • Of 2620 patients undergoing upper tract urological laparoscopic surgery, 14 patients (0.5%) sustained splenic injury and underwent left-sided surgery, 13 via a transperitoneal approach. • In 12 of the 14 patients, the splenic injury was recognized intraoperatively and all were effectively managed laparoscopically with a combination of argon beam coagulation, biological haemostatic agent FloSealTM (Baxter, Deerfield, IL, USA), and bio-absorbable Surgicel® (Johnson and Johnson, Somerville, NJ, USA); none of these patients required splenectomy or developed any postoperative complications. • In two patients, the splenic injury was not recognized intraoperatively; both patients presented with delayed haemorrhage necessitating open splenectomy in each instance. CONCLUSIONS • Splenic injuries are uncommon during laparoscopic urological surgery, but when a significant splenic injury occurs, it can be effectively managed laparoscopically, using conservative measures, without need for splenectomy. • If the splenic injury is not recognized intraoperatively, delayed haemorrhage is likely to occur necessitating emergent re-exploration and splenectomy. • Prompt and accurate intraoperative diagnosis of splenic injury is critical for achieving a good outcome. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To present our experience with single-port transvesical enucleation of the prostate (STEP) in 34 patients with large-volume benign prostatic hyperplasia (BPH). PATIENTS AND METHODS We performed STEP in 34 patients with large volume (>60 g) BPH (mean age 69 years, body mass index 26 kg/m2, and American Society of Anesthesiology class 2). The mean prostate volume estimated by transrectal ultrasonography was 102.5 mL and the mean baseline prostate-specific antigen level was 6.7 ng/mL. A novel single-port device was inserted percutaneously into the bladder through a 2–3 cm incision in the suprapubic skin crease. After establishing pneumovesicum, the prostate adenoma was enucleated transvesically using standard laparoscopic instruments, and the adenoma was extracted in pieces through the port. Digital assistance expedited enucleation of the apical adenoma in 19 (55%) cases. RESULTS Transvesical enucleation was completed in all 34 cases; the mean operative duration was 116 min, and the estimated blood loss was 460 mL. There was one death from postoperative bleeding from uncontrolled coagulopathy in a Jehovah’s Witness who refused a transfusion of blood and blood products. There were three complications during STEP (one death, one bowel injury and one haemorrhage) and five afterwards (four bleeding, one epididymo-orchitis). Open conversion was necessary in two patients for complications, and extension of the skin incision by 1–2 cm was necessary in two to expedite apical digital enucleation. The mean hospital stay was 3 days and mean analogue pain score at discharge was 2. All 33 patients (excluding the patient who died) were voiding spontaneously at a maximum follow-up of 8 months, with a mean American Urologic Association symptom score of 3, a maximum urinary flow rate of 44 mL/s, and a postvoid residual of 30 mL at the latest follow-up. No patient developed urinary incontinence. CONCLUSIONS STEP is an effective treatment option for selected patients with large-volume obstructive BPH. Under pneumovesicum using laparoscopic visualization, the entire adenoma can be effectively enucleated and expeditiously extracted through the novel single port. Comparison of the STEP procedure with other open and transurethral techniques will determine its place in the surgical treatment of large-volume BPH. [ABSTRACT FROM AUTHOR]

Objectives: To report our initial experience with laparoendoscopic single-site (LESS) surgery in 100 patients in urology. Methods: Between October 2007 and December 2008, we performed LESS urologic procedures in 100 patients for various indications. These included nephrectomy (N = 34; simple 14, radical 3, donor 17), nephroureterectomy (N = 2), partial nephrectomy (N = 6), pyeloplasty (N = 17), transvesical simple prostatectomy (N = 32), and others (N = 9). Data were prospectively collected in a database approved by the Institutional Review Board. All procedures were performed using a novel single-port device (r-Port) and a varying combination of standard and specialized bent/articulating laparoscopic instruments. Robotic assistance was used to perform LESS pyeloplasty (N = 2) and simple prostatectomy (N = 1). In addition to standard perioperative data, we obtained data on postdischarge analgesia requirements, time to complete convalescence, and time to return to work. Results: In the study period, LESS procedures accounted for 15% of all laparoscopic cases by the authors for similar indications. Conversion to standard multiport laparoscopy was necessary in 3 cases, addition of a single 5-mm port was necessary in 3 cases, and conversion to open surgery was necessary in 4 cases. On death occurred following simple prostatectomy in a Jehovah''s Witness due to patient refusal to accept transfusion following hemorrhage. Intra- and postoperative complications occurred in 5 and 9 cases, respectively. Mean operative time was 145, 230, 236, and 113 minutes and hospital stay was 2, 2.9, 2, and 3 days for simple nephrectomy, donor nephrectomy, pyeloplasty, and simple prostatectomy, respectively. Conclusions: The LESS surgery is technically feasible for a variety of ablative and reconstructive applications in urology. With proper patient selection, conversion and complications rates are low. Improvement in instrumentation and technology is likely to expand the role of LESS in minimally invasive urology. [Copyright &y& Elsevier]

Objectives: Natural orifice transluminal endoscopic surgery comprises intraabdominal surgery performed by way of natural orifices (ie, vagina, mouth). In a similar manner, the umbilicus provides an embryonic natural orifice that permits intraabdominal access. We report on the feasibility of performing single-port advanced laparoscopic reconstructive surgery by way of the umbilicus in 6 patients. We propose the terminology embryonic-natural orifice transluminal endoscopic surgery (E-NOTES) for this novel surgical approach. Methods: Through a single 1.5- to 3-cm intraumbilical incision and a novel, single-access port, we performed laparoscopic bilateral single-session Anderson-Hynes pyeloplasty (2 patients, 4 procedures), ileal ureter (n = 1), and ureteroneocystostomy with a psoas hitch (n = 1). No extraumbilical skin incisions were used. A 2-mm Veress needle port, inserted through a skin needle puncture, was used to create the pneumoperitoneum and to selectively insert a needlescopic grasper to assist in suturing. Results: All procedures were successful without the need for any additional laparoscopic ports. For the 2 patients undergoing bilateral pyeloplasty (including patient repositioning) and the 1 patient each undergoing ileal ureter and psoas-hitch ureteroneocystostomy, the operating time was 4.5, 6, 5, and 3 hours, blood loss was 100, 50, 75, and 50 mL, and the hospital stay was 1, 2, 3, and 2 days, respectively. No intraoperative or postoperative complications developed. Conclusions: To our knowledge, we present the initial experience with advanced laparoscopic reconstruction through a single intraumbilical port. Additional refinement of this technology could lead to wider incorporation of single-port laparoscopy in clinical practice. Embryonic-natural orifice transluminal endoscopic surgery appears to be a promising new approach for select indications. [Copyright &y& Elsevier]

OBJECTIVE To report the technical feasibility of performing transvesical robotic radical prostatectomy (TRRP) in a cadaver. MATERIALS AND METHODS TRRP was performed in two fresh male cadavers (prostate volume 46 and 30 mL). In the first procedure we used four laparoscopic transvesical trocars and in the second a single-port device was placed percutaneously into the bladder. Pneumovesicum was established in both cases and the da Vinci-S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was used for the TRRP. All steps of the procedure, including dissection of the seminal vesicles and vas deferens, ligation of prostatic pedicles, release of neurovascular bundles, apical dissection, urethral transection, and urethro-vesical anastomosis, were done transvesically and robotically. Real time transrectal ultrasonography monitoring was used in the first cadaver. RESULTS Both procedures were technically successful transvesically with no need for additional ports or conversion to standard laparoscopy. The operative duration for the multi-port procedure was 3 h and for the single-port procedure was 4.2 h. Clashing of the da Vinci arms was the primary technical difficulty with the single-port procedure, but did not occur in the multi-port procedure. CONCLUSIONS TRRP under pneumovesicum is technically feasible using multiple-port or a single-port approach in the cadaver. The clinical application of this novel approach is imminent. Further refinement of technique and instruments might lead to an increasing role of percutaneous intraluminal surgery in various surgical disciplines. [ABSTRACT FROM AUTHOR]

Introduction: To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. Methods: Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. Results: Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. Conclusions: Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia. [Copyright &y& Elsevier]

Abstract: Context: Single-port transumbilical laparoscopy, also known as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status is timely. Objective: To summarize and review the history of E-NOTES across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. Specific urological and nonurological applications of single-port surgery to date are summarized. Evidence acquisition: Using the National Library of Medicine database, the English-language literature was reviewed for the past 40 yr. Keyword searches included: scarless, scar free, single port/trocar/incision, intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. Evidence synthesis: The gynecologic and general surgical literature includes approximately 19 papers fulfilling the search criteria, encompassing extirpative procedures only. The urologic literature contains eight published reports of single-trocar transumbilical procedures. These reports are summarized in a chronological manner and grouped by subject. No prospective studies comparing outcomes to standard laparoscopy have been reported. Technical feasibility has been demonstrated for a broad range of extirpative and reconstructive procedures on the upper and lower urinary tracts, including simple and radical nephrectomy, donor nephrectomy, renal cryotherapy, pyeloplasty, ileal ureteral replacement, sacrocolpopexy, and varicocelectomy. Conclusions: E-NOTES has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role. [Copyright &y& Elsevier]

Objectives: To describe a novel flexible robotic system for performing retrograde intrarenal surgery. Methods: Remote robotic flexible ureterorenoscopy was performed bilaterally in 5 acute swine (10 kidneys). A novel 14F robotic catheter system, which manipulated a passive optical fiberscope mounted on a remote catheter manipulator was used. The technical feasibility, efficiency, and reproducibility of accessing all calices were assessed. Additionally, laser lithotripsy of calculi and laser ablation of renal papillae were performed. Results: The robotic catheter system could be introduced de novo in eight ureters; two ureters required balloon dilation. The ureteroscope could be successfully manipulated remotely into 83 (98%) of the 85 calices. The time required to inspect all calices within a given kidney decreased with experience from 15 minutes in the first kidney to 49 seconds in the last (mean 4.6 minutes). On a visual analog scale (1, worst to 10, best), the reproducibility of caliceal access was rated at 8, and instrument tip stability was rated at 10. A renal pelvic perforation constituted the solitary complication. Histologic examination of the ureter showed changes consistent with acute dilation without areas of necrosis. Conclusions: A novel robotic catheter system is described for performing retrograde ureterorenoscopy. The potential advantages compared with conventional manual flexible ureterorenoscopy include an increased range of motion, instrument stability, and improved ergonomics. Ongoing refinement is likely to expand the role of this technology in retrograde intrarenal surgery in the near future. [Copyright &y& Elsevier]

Associate Editor Ash Tewari Editorial Board Ralph Clayman, USA Inderbir Gill, USA Roger Kirby, UK Mani Menon, USA OBJECTIVE To report the initial clinical cases of scarless, single port, transumbilical nephrectomy and pyeloplasty. PATIENTS AND METHODS One patient each underwent single port transumbilical nephrectomy and pyeloplasty using the R-Port (Advanced Surgical Concepts), inserted through a transumbilical incision in both cases. Novel, specialized instruments, curved at the shaft, were used in addition to standard laparoscopic instrumentation. During pyeloplasty, a 2-mm needle-port (MiniSite, USSC, Norfolk, CT, USA) was also inserted, with no skin incision, to facilitate suturing. RESULTS Both procedures were technically successful with no extra-umbilical skin incisions. The total operative duration was 3.4 and 2.7 h, the estimated blood loss 100 and 50 mL, and the hospital stay was 1 and 2 days for the nephrectomy and pyeloplasty, respectively. There were no complications during or after surgery. The total analgesia requirement was 100 and 150 mg of keterolac, and visual analogue pain scores were 8/10 and 2/10 at 1 and 2 days after surgery, respectively. CONCLUSIONS Transumbilical, single port nephrectomy and pyeloplasty are technically feasible. The first initial clinical experience of organ-ablative and reconstructive renal surgery with this approach is reported. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To evaluate the effect of pyeloplasty for the treatment of ureteropelvic junction (UPJ) obstruction on adult renal function in the setting of a solitary kidney. Methods: Since 1989, 312 patients have undergone operative intervention for UPJ obstruction. Of these, 13 patients (5 men and 8 women), aged 17 to 76 years (median 44.5), had a solitary kidney and were available for postoperative surveillance. Treatment consisted of endopyelotomy (n = 3), laparoscopic dismembered pyeloplasty (n = 3), and open dismembered pyeloplasty (n = 9). Two patients underwent two separate interventions for UPJ obstruction repair. Success was defined as symptomatic relief and radiographic resolution at the latest follow-up visit. In all patients, serum creatinine, estimated glomerular filtration rate, and weight were measured preoperatively, postoperatively, and at all follow-up examinations. Statistical analysis was performed to analyze group differences using the Wilcoxon signed-rank test. Results: The median follow-up was 22 months (range 2 to 96). Three patients experienced a treatment failure and were excluded from the analysis. At the latest follow-up visit, the postoperative serum creatinine had improved by a median of 0.6 mg/dL (range −0.2 to 6.3; P <0.0001), and postoperative estimated glomerular filtration rate had improved by a median of 24.4 mL/min (range −13.9 to 66; P <0.0001). No statistically significant difference in renal function was observed between the patients’ first and last follow-up visits. Conclusions: Operative intervention for the treatment of adult UPJ obstruction may result in symptomatic relief and, perhaps more importantly, renal functional improvement. These findings are important for effectively counseling patients and considering indications for intervention. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the long-term clinical and radiographic success of holmium laser endoureterotomy for nonobliterative benign ureteral strictures. Methods: A total of 19 patients (12 women and 7 men, mean age 47.5 years) underwent holmium laser endoureterotomy for iatrogenic ureteral strictures (seven proximal, seven mid, and five distal) using semirigid ureteroscopy and a 360-μm fiber at 1 J and 10 Hz. Results: Success was strictly defined as both relief of symptoms and radiographic resolution of obstruction by intravenous pyelography or diuretic renography, or both. With a median follow-up of 3.0 years, success was achieved in 13 (68.4%) of 19 patients. Conclusions: Our results have shown that holmium laser endoureterotomy is associated with a long-term success rate equivalent to, or better than, other currently available minimally invasive treatment options. Also, failure was uniformly evident within the first 3 months after treatment. [Copyright &y& Elsevier]

Abstract: We sought to compare perioperative and short-term outcomes of laparoscopic partial nephrectomy versus laparoscopic cryoablation in patients with peripheral small renal tumors. Prospectively accrued data of patients with a small renal tumor (≤3 cm) undergoing laparoscopic partial nephrectomy (group 1, n = 153) or laparoscopic cryoablation (group 2, n = 78) were compared retrospectively. Patients undergoing laparoscopic partial nephrectomy were younger (mean age, 60.6 vs 65.6 years; P = 0.005), healthier (American Society of Anesthesiologists class 3/4 present in 46% vs 75%; P = 0.001), had a lower baseline serum creatinine (90.1 vs 106.0 μmol/L [1.02 vs 1.2 mg/dL]; P = 0.01), a larger tumor size (2.3 vs 2.1 cm; P = 0.02), and fewer cases of solitary kidneys (5% vs 23%; P = 0.000). Laparoscopic partial nephrectomy was associated with greater blood loss (211 vs 101 mL; P = 0.000) and a higher incidence of delayed complications after hospital discharge (16.3% vs 2.2%; P = 0.01) compared with cryoablation. Both groups were comparable with regard to operative time (P = 0.77), intraoperative complications (P = 0.1), postoperative complications (P = 0.55), hospital stay (P = 0.13), convalescence (P = 0.96), and postoperative serum creatinine (112.2 vs 123.7 μmol/L [1.27 vs 1.4 mg/dL]; P = 0.31). Local recurrence was detected over a mean follow-up time of 5.8 months in group 1 (0.6%) and 24.6 months in group 2 (3%). Although the technical simplicity, decreased blood loss, and somewhat lower complication rate are attractive features of renal cryotherapy, this must be balanced against the current lack of long-term follow-up data that are needed to confirm the oncologic adequacy of this developmental procedure. Laparoscopic partial nephrectomy, albeit a technically advanced procedure, duplicates established open principles and has therefore evolved to become our current minimally invasive nephron-sparing procedure of choice in the majority of patients with a small renal tumor. [Copyright &y& Elsevier]

Examines the status of laparoscopic partial nephrectomy (LPN) for tumor at the Cleveland Clinic Foundation in Cleveland, Ohio. Role of renal hilar clamping and impact of warm ischemia on LPN; Feasibility of achieving reliable laparoscopic renal hypothermia during LPN; Analysis of complications in the initial 200 patients undergoing LPN for renal tumor.

Examines the clinical status of percutaneous endopyeloplasty. Basis of endopyelotomy on the principle of the intubated ureterotomy; Use of SewRite SR5, a 5-mm laparoscopic suturing instrument used for placing interrupted sutures; Comparison between endopyelotomy and laparoscopic pyeloplasty.

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage.To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function.Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN.In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age≥70 years and a serum creatinine level after LPN of≥1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN.The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of≈ 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min. [ABSTRACT FROM AUTHOR]

Objectives: To present our intermediate-term (1-year) data on endopyeloplasty and retrospectively compare it with endopyelotomy and laparoscopic pyeloplasty in 44 patients with primary ureteropelvic junction (UPJ) obstruction. Endopyeloplasty, horizontal percutaneous suturing of a conventional longitudinal endopyelotomy incision, is a promising novel option for minimally invasive management of UPJ obstruction. We recently developed the technique and demonstrated the clinical feasibility of percutaneous endopyeloplasty.Methods: At our two institutions, 44 consecutive, nonrandomized patients with primary UPJ obstruction underwent percutaneous endopyeloplasty (n = 15; group 1), percutaneous endopyelotomy (n = 15; group 2), or laparoscopic dismembered pyeloplasty (n = 14; group 3). The study inclusion criteria were short segment (less than 1 cm) stenosis, no prior surgery for UPJ obstruction, and no crossing vessels in groups 1 and 2. The mean patient age was 30.3, 38.6, and 38.9 years and the duration of symptoms was 5.5, 6, and 6.6 months in groups 1, 2, and 3, respectively. Postoperative success was evaluated by symptoms, intravenous urography, and/or diuretic renography.Results: The mean operative time was 119 minutes in group 1, 52 minutes in group 2, and 243 minutes in group 3 (P <0.001). Complications occurred in 3 patients in group 1 (fever in 2 and fluid extravasation in 1), 2 patients in group 2 (bleeding in 1 and urinoma in 1), and no patients in group 3. The duration of double-J stent placement was 2, 4, and 6 weeks in groups 1, 2, and 3, respectively. A resolution of symptoms and unobstructed drainage on intravenous urography and/or diuretic renography was noted in 100% and 100% of patients in group 1 (mean follow-up 11.6 months), 93% and 88% of patients in group 2 (mean follow-up 31.4 months), and 93% and 100% of patients in group 3 (mean follow-up 20 months).Conclusions: The results of this retrospective comparison of patients with primary UPJ obstruction suggest that percutaneous endopyeloplasty may have functional superiority over percutaneous endopyelotomy. The technical simplicity and shorter operative time of endopyeloplasty are advantages compared with laparoscopic pyeloplasty. Endopyeloplasty may be associated with a shorter duration of stenting compared with the other techniques. Longer term follow-up in a larger group of patients from multiple centers and a prospective randomized comparison among these various minimally invasive approaches are necessary to validate these preliminary results. [Copyright &y& Elsevier]

: ObjectivesLaparoscopic partial nephrectomy is emerging as a viable minimally invasive nephron-sparing option for select patients with an exophytic renal tumor. With increasing experience, we are applying laparoscopic partial nephrectomy to tumors invading more deeply into the renal parenchyma, necessitating intentional caliceal entry to ensure an adequate margin of resection. In this prospective study, we assessed the safety and efficacy of such substantive renal parenchymal resections that incorporate laparoscopic suture repair of the collecting system.: MethodsSince August 1999, laparoscopic partial nephrectomy was performed in 64 patients with a renal tumor. Our technique routinely involved transient clamping of the renal artery and vein, caliceal suture repair (if necessary), and renal parenchymal suture repair. Intraoperative and postoperative data from the group requiring caliceal repair (group 1, n = 27) were compared with those not requiring caliceal repair (group 2, n = 37). The mean tumor size was 3.4 ± 1.6 cm in group 1 and 2.6 ± 0.9 cm in group 2 (P = 0.02). The mean depth of tumor invasion into the renal parenchyma was 1.5 ± 0.8 cm in group 1 and 0.9 ± 0.3 cm in group 2 (P = 0.15).: ResultsLaparoscopic partial nephrectomy was technically successful in all 64 cases without any open conversions. Both groups 1 and 2 were comparable in terms of total operative time (3.2 ± 0.9 hours versus 2.7 ± 1.0 hours, P = 0.06), tumor excision time (5.9 ± 1.8 minutes versus 6.0 ± 1.9 minutes, P = 0.97), and estimated blood loss (241 ± 306 mL versus 258 ± 342 mL, P = 0.27). Pelvicaliceal suture repair was associated with a longer warm ischemia time (30.2 ± 5.4 minutes versus 19.4 ± 4.9 minutes, P <0.0001), and a greater hospital stay (3.0 ± 1.7 days versus 1.8 ± 1.2 days, P = 0.003). No patients in group 1, and 1 patient in group 2, developed an asymptomatic perinephric urinoma that was drained percutaneously. On pathologic examination, inked surgical margins were negative for cancer in all but 1 case; the width of the parenchymal margin on histologic examination was 0.5 ± 0.4 cm in group 1, and 0.4 ± 0.3 cm in group 2 (P = 0.59). The mean preoperative and postoperative serum creatinine was 1.1 and 1.2 mg/dL in group 1 and 1.0 and 1.1 mg/dL in group 2, respectively (P = 0.4). During a mean follow-up of 9.5 ± 3.5 months in group 1 and 15.7 ± 4 months in group 2, no renal unit developed irreversible ischemic damage or local cancer recurrence.: ConclusionsLaparoscopic partial nephrectomy can be performed safely and efficaciously for select invasive renal tumors with intrarenal extension, even up to the collecting system. Intentional caliceal entry in such cases can be effectively repaired in a watertight manner by laparoscopic freehand suturing, albeit with longer mean operative and warm ischemia times, without adverse renal functional sequelae. [Copyright &y& Elsevier]

: IntroductionRemote robotic telemanipulators have been recently used in performing laparoscopic urologic procedures, both in the laboratory and in clinical practice. We present, to our knowledge, the initial 2 cases of robotic-assisted laparoscopic adrenalectomy in humans.: Technical considerationsRobotic-assisted laparoscopic adrenalectomy (one right, one left) was performed in 2 patients with an adrenal tumor (one nonfunctional, one pheochromocytoma). Patient age was 81 and 47 years, and tumor size was 4.5 and 3 cm, respectively. Both cases were performed transperitoneally using the da Vinci Robotic Surgical System. Robotic-assisted laparoscopic adrenalectomy was successful in both cases without conversion to conventional laparoscopy or open surgery. The operative time was 110 and 165 minutes, the blood loss was 50 and 100 mL, and the hospital stay was 2 and 3 days. No intraoperative or postoperative complications occurred.: ConclusionsRobotic-assisted laparoscopic adrenalectomy is technically feasible. With increasing experience and refinement in the technology, the role of robotics in urologic laparoscopy is likely to expand. [Copyright &y& Elsevier]

We report a case of a patient who presented with inability to walk for 2 days which was acute in onset, with no history or preceeding trauma. On examination it was found to have stable vitals. Both lower limbs were in the flexed, abducted & externally rotated attitude, with no sensory motor deficit. Radiological investigations revealing osteoporosis and bilateral fracture neck of femur and blood investigations indicated severe vitamin D deficiency. [ABSTRACT FROM AUTHOR]

Purpose: To report perioperative and long-term postoperative outcomes of cystectomy patients with ileal conduit (IC) urinary diversion undergoing parastomal hernia (PSH) repair. Method: We reviewed patients who underwent cystectomy and IC diversion between 2003 and 2022 in our center. Baseline variables, including surgical approach of PSH repair and repair technique, were captured. Multivariable Cox regressionanalysis was performed to test for the associations between different variables and PSH recurrence. Results: Thirty-six patients with a median (IQR) age of 79 (73–82) years were included. The median time between cystectomy and PSH repair was 30 (14–49) months. Most PSH repairs (32/36, 89%) were performed electively, while 4 were due to small bowel obstruction. Hernia repairs were performed through open (n=25), robotic (10), and laparoscopic approaches (1). Surgical techniques included direct repair with mesh (20), direct repair without mesh (4), stoma relocation with mesh (5), and stomarelocation without mesh (7). The 90-day complication rate was 28%. In a median follow-up of 24 (7–47) months, 17 patients (47%) had a recurrence. The median time to recurrence was 9 (7–24) months. On multivariable analysis, 90-day complication following PSH repair was associated with an increased risk of recurrence. Conclusions: In this report of one of the largest series of PSH repair in the Urology literature, 47% of patients had a recurrence following hernia repair with a median follow-up time of 2 years. There was no significant difference in recurrence rates when comparing repair technique or the use of open or minimally invasive approaches. [ABSTRACT FROM AUTHOR]

Introduction: We examine the heterogeneity and distribution of the cohort populations in two publicly used radiological image cohorts, the Cancer Genome Atlas Kidney Renal Clear Cell Carcinoma (TCIA TCGA KIRC) collection and 2019 MICCAI Kidney Tumor Segmentation Challenge (KiTS19), and deviations in real-world population renal cancer data from the National Cancer Database (NCDB) Participant User Data File (PUF) and tertiary center data. PUF data are used as an anchor for prevalence rate bias assessment. Specific gene expression and, therefore, biology of RCC differ by self-reported race, especially between the African American and Caucasian populations. AI algorithms learn from datasets, but if the dataset misrepresents the population, reinforcing bias may occur. Ignoring these demographic features may lead to inaccurate downstream effects, thereby limiting the translation of these analyses to clinical practice. Consciousness of model training biases is vital to patient care decisions when using models in clinical settings. Methods: Data elements evaluated included gender, demographics, reported pathologic grading, and cancer staging. American Urological Association risk levels were used. Poisson regression was performed to estimate the population-based and sample-specific estimation for prevalence rate and corresponding 95% confidence interval. SAS 9.4 was used for data analysis. Results: Compared to PUF, KiTS19 and TCGA KIRC oversampled Caucasian by 9.5% (95% CI, −3.7 to 22.7%) and 15.1% (95% CI, 1.5 to 28.8%), undersampled African American by −6.7% (95% CI, −10% to −3.3%), and −5.5% (95% CI, −9.3% to −1.8%). Tertiary also undersampled African American by −6.6% (95% CI, −8.7% to −4.6%). The tertiary cohort largely undersampled aggressive cancers by −14.7% (95% CI, −20.9% to −8.4%). No statistically significant difference was found among PUF, TCGA, and KiTS19 in aggressive rate; however, heterogeneities in risk are notable. Conclusion: Heterogeneities between cohorts need to be considered in future AI training and cross-validation for renal masses. [ABSTRACT FROM AUTHOR]

Coronal mass ejections and solar flares release huge quantities of energized matter, magnetic fields and electromagnetic radiation into space. The high-energy particles, known as solar energetic particles or SEPs, present a serious radiation threat to human explorers living and working outside low-Earth orbit and to technological assets such as communications and scientific satellites in space. Our current understanding of SEPs is hampered because the near-Earth observations are influenced by multiple effects such as the identity of the suprathermal seed populations, the mechanisms by which these seed particles are selected and accelerated to higher energies, and lastly, how interplanetary turbulence and large-scale solar wind structures affect their transport to Earth orbit. One of the major goals of NASA's Parker Solar Probe (PSP) mission is to determine the mechanisms that accelerate and transport high-energy particles from the solar atmosphere out into the heliosphere. PSP will revolutionize our understanding of SEPs by making the first-ever direct measurements of key properties such as intensities, energy spectra, composition, and angular distributions of both the low-energy suprathermal source populations as well as the more hazardous, higher energy particles in the near-Sun environment where the acceleration takes place. This talk discusses key areas in which PSP will provide ground-truth observations that will serve as definitive tests for current SEP models. [ABSTRACT FROM AUTHOR]

Interstellar pickup ions (PUI) are interstellar neutrals that have been ionized in transit through the heliosphere via charge exchange or photoionization. These new PUIs then "freeze" into the solar wind (SW) and move with the bulk SW velocity (VSW). They also begin to gyrate around the local magnetic field with VSW, resulting in a maximum PUI velocity of 2 ∗ VSW. Understanding how He+ PUIs are accelerated at shocks in space provides valuable insights into shock dynamics and shock acceleration mechanisms. On 2018 January 8, while the Magnetospheric Multiscale (MMS) Mission was in the SW, it observed the forward shock of a corotating interaction region. In this work, we analyze the upstream and downstream velocity distributions of He+ for this quasiperpendicular, marginally supercritical (θBn = 67°, MA = 2.8) interplanetary shock. We derive average two-dimensional pitch-angle distributions in the field-aligned SW frame, as well as reduced one-dimensional velocity distributions for selected upstream and downstream intervals. We find that the shock accelerates He+ largely perpendicular to the magnetic field, consistent with shock reflection. Furthermore, we derive a measured ratio of accelerated He+ ions by estimating a maximum speed in the downstream frame, above which we assume that He+ ions have been accelerated by their interaction with the shock. The measured acceleration ratio, RMeasured = 0.14, is then compared to a theoretical ratio derived from a simple model of the upstream distribution, RTheoretical = 0.06. [ABSTRACT FROM AUTHOR]

Current imaging and laboratory modalities have suboptimal diagnostic and prognostic accuracy in patients with upper tract urothelial carcinoma (UTUC). Blood-based liquid biopsy has emerged as a novel biomarker to improve the diagnosis and monitoring of urothelial tumors while enabling individualized risk stratification. In this study, we aimed to systematically visualize and characterize rare events, including circulating tumor cells (CTCs) and oncosomes, present in the peripheral blood collected from primary UTUCs, to assess the efficacy of these novel biomarkers in the diagnosis, surveillance, and prognosis of these patients. In this prospective study, under an IRB-approved protocol (#HS-19-00886), peripheral blood samples were collected from primary UTUC patients before extirpative surgery with curative intent and follow-up visits between May 2021 and September 2022. The samples were analyzed using the third-generation comprehensive high-definition single-cell assay (HDSCA3.0) to detect rare events, including CTCs and oncosomes based on the immunofluorescent signals of DAPI (D), cytokeratin (CK), CD45/CD31 (CD), and vimentin (V). The findings of pre-surgery liquid biopsies were compared to the 50 blood samples of normal blood donors (NDs), and follow-up liquid biopsy findings were evaluated and compared to the pre-surgery results. The association between liquid biopsy findings and progression-free survival (PFS) was also assessed. Twenty-eight patients with a median age of 67.5 years were included, of whom 21 had follow-up samples. Pathologic staging revealed 15 pT<2 and 13 pT≥2 tumors, and most cases (23/28) were high-grade. Significant differences in specific rare analytes, including total oncosomes, D|V cells, total events, total cells, CK oncosomes, D|CK|V|CD cells, total CK cells, D|V|CD cells, CK|CD oncosomes, and D only cells, were detected in pre-op UTUC samples as compared to NDs. On the post- vs. pre-surgery matched analysis, a significant decrease was detected in total, CK, and CK|V oncosomes as well as D, D|V, and D|V|CD cells (Figure 1). With a median follow-up of 11 months, seven patients had disease recurrence. Survival analysis demonstrated that patients with positive preoperative CK|V LEV and those with post- vs. pre-surgery positive change in CK|V LEV level had worse PFS compared to other patients (p=0.02 and p=0.009, respectively) (Figure 2). This study demonstrates promising evidence for the possible clinical utility of blood-based liquid biopsy biomarkers, including CTCs and oncosomes, in the diagnosis and surveillance of patients with UTUC. In addition, pre-surgery CK|V oncosome levels can be used for PFS estimation. A study with a larger sample size, additional follow-up samples, and a more comprehensive genomic analysis is the next step. [ABSTRACT FROM AUTHOR]

Annually, about 300 million surgeries lead to significant intraoperative adverse events (iAEs), impacting patients and surgeons. Their full extent is underestimated due to flawed assessment and reporting methods. Inconsistent adoption of new grading systems and a lack of standardization, along with litigation concerns, contribute to underreporting. Only half of relevant journals provide guidelines on reporting these events, with a lack of standards in surgical literature. To address these issues, the Intraoperative Complications Assessment and Reporting with Universal Standard (ICARUS) Global Surgical Collaboration was established in 2022. The initiative involves conducting global surveys and a Delphi consensus to understand the barriers for poor reporting of iAEs, validate shared criteria for reporting, define iAEs according to surgical procedures, evaluate the existing grading systems' reliability, and identify strategies for enhancing the collection, reporting, and management of iAEs. Invitation to participate are extended to all the surgical specialties, interventional cardiology, interventional radiology, OR Staffs and anesthesiology. This effort represents an essential step towards improved patient safety and the well-being of healthcare professionals in the surgical field. [ABSTRACT FROM AUTHOR]