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There has been a recent shift in medical student anatomy education with greater incorporation of virtual resources. Multiple approaches to virtual anatomy resources have been described, but few involve video or images from surgical procedures. In this pilot study, a series of surgical case videos was created using robotic surgery video footage for a first‐year medical student anatomy course. Five operations were included that covered thoracic, abdominal, and pelvic anatomy. Students were surveyed at the end of the course regarding their experience with the videos and their perceptions towards a surgical career. Overall, participants agreed that the videos were an effective learning tool, were useful regardless of career interest, and that in the future it would be useful to incorporate additional surgical case videos. Respondents highlighted the importance of audio narration with future videos and provided suggestions for future operations that they would like to see included. In summary, this pilot study describes the creation and implementation of a surgical video anatomy curriculum and student survey results suggest this may be an effective approach to video‐based anatomy education for further curricular development. [ABSTRACT FROM AUTHOR]

Cadaver dissection has always played a fundamental role in medical education. However, especially in Italy, the topic of body donation has remained partially unknown for years. The current study analyses graphic medicine as a new possible communication tool, evaluating and reflecting, with second‐year students enrolled in the International School of Medicine and Surgery at the University of Bologna, about its potentialities for body donation awareness‐raising in both the scientific community and the general population. For the first time in an Italian University, two graphic medicine workshops were organized focusing on human anatomy and body donation. Seminars were positively evaluated by students using a four items Likert‐scale question: mean 3.54 (± SD 0.73) for the Likert question about the experiences of the workshops; 3.88 (± 0.33) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the general population; 3.59 (± 0.65) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the scientific community. Furthermore, the open‐ended questions included in the anonymous questionnaire were analyzed using the constructivist grounded qualitative analysis, whence various themes emerged. Finally, five graphic medicine projects about body donation were created by students, proving their interest in testing this method to promote body donation, focusing the attention on different communicative aspects. Considering the results of this pilot study, the co‐creative collaborative use of graphic medicine could be evaluated as an additional strategy to increase body donation awareness‐raising in Italy and beyond, especially in the non‐experts' community. [ABSTRACT FROM AUTHOR]

Introduction: Erectile dysfunction is associated with diabetes mellitus with an estimated prevalence of 52.5% in the diabetic population. The first-line therapy for erectile dysfunction is phosphodiesterase type 5 inhibitors, but data suggest that diabetic men may be less responsive than non-diabetic men. Thus, other treatments, including intracavernosal injections, intraurethral prostaglandin, vacuum erection devices and penile prosthetic surgery, should be considered in management of diabetic men with erectile dysfunction refractory to phosphodiesterase type 5 inhibitors. Furthermore, combination therapy of phosphodiesterase type 5 inhibitors and other oral treatments such as arginine or L-carnitine may have synergistic effects resulting in better outcomes. In addition, there are novel therapies such as low-intensity shockwave therapy and stem-cell therapy, which may also be effective in targeted treatment modalities. Furthermore, studies suggest that erectile dysfunction can be improved by targeting concurrent comorbidities or metabolic diseases such as depression, hypertension, hypogonadism, and dyslipidaemia. We present an evidence-based narrative review focusing on the management of erectile dysfunction in diabetic men who have not responded to phosphodiesterase type 5 inhibitors. Conclusions: Both clinicians and patients should be aware of the different management options in diabetic patients who have not responded to phosphodiesterase type 5 inhibitors. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a highly prevalent disease characterized by hyperglycaemia that damages the vascular system, leading to micro- (retinopathy, neuropathy, nephropathy) and macrovascular diseases (cardiovascular disease). There are also secondary complications of diabetes (cardiomyopathy, erectile dysfunction or diabetic foot ulcers). Stem cell-based therapies have become a promising tool targeting diabetes symptoms and its chronic complications. Among all stem cells, adipose-derived mesenchymal stem cells (ADMSCs) are of great importance because of their abundance, non-invasive isolation and no ethical limitations. Characteristics that make ADMSCs good candidates for cell-based therapy are their wide immunomodulatory properties and paracrine activities through the secretion of an array of growth factors, chemokines, cytokines, angiogenic factors and anti-apoptotic molecules. Besides, after transplantation, ADMSCs show great ex vivo expansion capacity and differentiation to other cell types, including insulin-producing cells, cardiomyocytes, chondrocytes, hepatocyte-like cells, neurons, endothelial cells, photoreceptor-like cells, or astrocytes. Preclinical studies have shown that ADMSC-based therapy effectively improved visual acuity, ameliorated polyneuropathy and foot ulceration, arrested the development and progression of diabetic kidney disease, or alleviated the diabetes-induced cardiomyocyte hypertrophy. However, despite the positive results obtained in animal models, there are still several challenges that need to be overcome before the results of preclinical studies can be translated into clinical applications. To date, there are several clinical trials or ongoing trials using ADMSCs in the treatment of diabetic complications, most of them in the treatment of diabetic foot ulcers. This narrative review summarizes the most recent outcomes on the usage of ADMSCs in the treatment of long-term complications of diabetes in both animal models and clinical trials., (© 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Objective: Urinary incontinence (UI) is one of the most common complications of radical prostatectomy (RP). Impaired urethral sphincter function is generally considered to be the most important contributing factor for UI; however, the mechanism of onset and recovery of urinary continence has not been fully elucidated. The objective of this research was to evaluate preoperative functional urethral length (FUL) and maximum urethral closure pressure (MUCP) as early continence recovery predictors after open retropubic RP (ORRP).Methods: The research was conducted on a group of 43 patients with localized prostate cancer (PCa) in the period from July 2019 to May 2021. The urodynamic method of urethral pressure profile (UPP) was used to assess FUL and MUCP, and correlate with the postprostatectomy continence recovery. The severity of UI and bothersome were assessed using fully validated International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ‐UI SF) and number of pads used in 24 h. Patients were interviewed about the use of urinary pads and asked to fill out the ICIQ‐UI SF before and 2, 8, 16 and 24 weeks after ORRP.Results: The median value of FUL (mm) and MUCP (cmH2O) was 69 (28–94) and 76 (16–223), respectively. Correlation and linear regression showed a statistically significant negative correlation between preoperative values of FUL and MUCP with ICIQ symptom score and the number of pads used per day at the four observed time intervals (p < 0.05). Such a result showed that patients with higher preoperative FUL and MUCP values were more likely to recover urinary continence earlier. A value of 65 mm for FUL and 80 cmH2O for MUCP proved to be the cut‐off values for continence recovery in 24 weeks after ORRP.Conclusion: Preoperatively evaluated FUL and MUCP seem to be valuable prognostic factors for early continence recovery after ORRP. Further investigation on a larger patient cohort is needed to evaluate the role of UPP in the preoperative management of patients with PCa. [ABSTRACT FROM AUTHOR]

Treatment of urolithiasis, a benign disease, requires high efficacy and safety. Endoscopic treatment of impacted ureteral stones remains a challenging procedure for urologists, despite recent remarkable advances in surgical technology in treatment of urolithiasis. The success rate of endoscopic treatment in patients with impacted stones is reported to be lower than that in patients with nonimpacted stones. Moreover, the presence of stone impaction is associated with high rates of intraoperative and postoperative complications. The best management for patients with impacted ureteral stones should therefore be devised based on the latest knowledge and techniques. The present review focuses on the preoperative prediction of stone impaction, the safest and most effective endoscopic surgical procedures, and the most appropriate management for postoperative ureteral strictures. We overview comprehensive endoscopic management for impacted ureteral stones based on literature review and expert opinions. [ABSTRACT FROM AUTHOR]

Majority of current treatment strategies against erectile dysfunction (ED) has been consisted of only a supportive care to sustain enough erection during a sexual intercourse. In this study, we investigated whether the cultured conditioned medium of human exfoliated deciduous dental pulp stem cells (SHED‐CM) had an ability to treat ED through fundamentally repairing the pathological damage of vascular endothelial cells of the corpus cavernosum. An open‐label pilot study was performed from April 2016 to October 2020. SHED‐CM was injected directly into the corpus cavernosum of penis of 38 ED patients who visited our clinic and fulfilled the inclusion criteria. Efficacy was assessed using the simplified International Index of Erectile Function (IIEF‐5) questionnaire. The average age and initial IIEF‐5 score of the patients enrolled in this study was 56 (31–79) years old and 13.1 (5–20) points, respectively. Medical history revealed 7 patients with diabetes, 7 patients with hypertension and 1 patient with priapism undergone shunt operation. Of these, 37 patients (97.4%) showed an improvement in IIEF‐5 of an average of 19.3 (7–25) points or 64.4 (10–300) % increase after three injections of SHED‐CM. Eighteen patients (47.4%) achieved more than 21 points (no ED) in IIEF‐5. No adverse events were encountered. This is the first clinical report of ED treatment in the literatures evaluating the efficacy of SHED‐CM. Treatment with SHED‐CM is expected to repair vascular damages of the corpus cavernosum, which are the main cause of ED, and to be widely spread as a fundamental clinical application for ED. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. Patients and Methods: Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion‐related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self‐reported inability to void without a catheter. Uni‐ and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. Results: Self‐catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m2) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26–4.32) as well as retention (HR 5.20, 95% CI 1.74–15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02–3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. Conclusion: In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m2 are at significantly increased risk of retention and need for self‐catheterisation. [ABSTRACT FROM AUTHOR]

Introduction: We evaluated the efficacy and safety of laparoscopic ureterolithotomy (LPU) for the treatment of large proximal ureteric stone. Methods: A retrospective multicenter analysis for patients with solitary impacted proximal ureteric stone ≥15 mm who underwent LPU from 2016 to 2019 was performed. Primary outcome was to estimate the stone‐free rate (SFR). SFR was defined as absence of residual stones on postoperative computed tomography scan. Secondary outcome was to assess the perioperative outcomes, as well as to review literature data of randomized controlled trials and meta‐analyses comparing LPU to other treatment options. Results: Forty‐four patients were included in our study. Mean stone size was 22.9 ± 5.8 mm and median follow‐up was 14 months. Three patients had previous abdominal surgery, one patient had severe degree of scoliosis and six patients failed primary therapy. All stones were extracted successfully (SFR = 100%) without need of auxiliary treatments. Mean operative time and estimated blood loss were 86.6 ± 14.1 minutes. and 11.9 ± 14.7 mL, respectively. No intraoperative complications or conversion to open surgery were reported. No major postoperative complications (≥grade 3) were reported. Mean length of hospital stay was 2 ± 0.8 days. Conclusions: For treatment of large ureteric stones, our study showed that LPU achieves 100% stone‐free status. When performed by well‐trained laparoscopic surgeons, it is safe and has no major perioperative complications. According to our results and literature data, when counseling patients with large impacted proximal ureteral stones, LPU should be advised as the procedure that has the higher SFR, lower auxiliary treatments, and comparable complication rates to other treatments. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the literature in order to investigate the efficacy and safety of surgical and non‐invasive penile enhancement procedures for aesthetic and therapeutic purposes. Methods: A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. Results: Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty‐nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty‐five studies evaluated non‐invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non‐invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing. Conclusion: The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications. [ABSTRACT FROM AUTHOR]

Objectives: Pubectomy is an ancillary technique used to increase exposure of the disrupted urethra and reduce anastomotic tension, which can be difficult for inexperienced surgeons. The objective of the present study was to illustrate the use of an air drill enabling delicate and precise bone resection in pubectomy for delayed anastomotic urethroplasty for pelvic fracture urethral injury. Methods: Between 2009 and 2019, 88 male patients underwent delayed anastomotic urethroplasty with pubectomy for pelvic fracture urethral injury. A total of 73 procedures used a high-speed surgical air drill (HiLAN HS; Aesculap, Tuttlingen, Germany) equipped with a short-hand piece. Operative time and blood loss in the air drill patient group (group 1) were compared with that of patients who underwent pubectomy using a rongeur and/or gouge (group 2, n = 15). Results: In 65 group 1 patients, urethroplasty was carried out using the perineal approach, with partial inferior pubectomy. Eight group 1 patients, whose proximal urethral end was displaced upward superior to the upper edge of pubis, underwent urethroplasty using the perineal and abdominal approach, with a superior partial pubectomy and supracrural urethral rerouting. No difficulty was encountered using the air drill in any of the cases. There was no significant difference in median operative time between the groups (group 1 256 min vs group 2 228 min; P = 0.31). The median blood loss in group 1 was significantly lower than group 2 (149 mL vs 453 mL; P < 0.0001). Conclusions: Surgical air drills might facilitate pubectomy in patients undergoing delayed anastomotic urethroplasty for pelvic fracture urethral injury. This tool offers the advantage of a delicate bone resection with reduced blood loss. [ABSTRACT FROM AUTHOR]

Introduction: Erectile dysfunction is associated with diabetes mellitus with an estimated prevalence of 52.5% in the diabetic population. The first-line therapy for erectile dysfunction is phosphodiesterase type 5 inhibitors, but data suggest that diabetic men may be less responsive than non-diabetic men. Thus, other treatments, including intracavernosal injections, intraurethral prostaglandin, vacuum erection devices and penile prosthetic surgery, should be considered in management of diabetic men with erectile dysfunction refractory to phosphodiesterase type 5 inhibitors. Furthermore, combination therapy of phosphodiesterase type 5 inhibitors and other oral treatments such as arginine or l-carnitine may have synergistic effects resulting in better outcomes. In addition, there are novel therapies such as low-intensity shockwave therapy and stem-cell therapy, which may also be effective in targeted treatment modalities. Furthermore, studies suggest that erectile dysfunction can be improved by targeting concurrent comorbidities or metabolic diseases such as depression, hypertension, hypogonadism, and dyslipidaemia. We present an evidence-based narrative review focusing on the management of erectile dysfunction in diabetic men who have not responded to phosphodiesterase type 5 inhibitors., Conclusions: Both clinicians and patients should be aware of the different management options in diabetic patients who have not responded to phosphodiesterase type 5 inhibitors., (© 2022 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

Aims: To review current prevention strategies for urinary incontinence among patients undergoing radical prostatectomy (RP). Methods: This is a consensus report of the proceedings of a research proposal from the annual International Consultation on Incontinence‐Research Society (ICI‐RS), 14 to 16 June 2018 (Bristol, UK): "How can we prevent postprostatectomy incontinence by patient selection, and by preoperative, peroperative, and postoperative measures?" Results: Several baseline parameters were proposed as predicting factors for postprostatectomy urinary incontinence (PPUI), including age, tumor stage, prostate volume, preoperative lower urinary tract symptoms, maximum urethral closure pressure, and previous transurethral resection of the prostate. More recently, magnetic resonance imaging has been used to measure the membranous urethral length and sphincter volume. Peroperative techniques include preservative and reconstructive approaches. Bladder neck preservation improved early (6 months), as well as long‐term (>12 months) continence rates. Several prospective studies have reported earlier return of continence following preservation of puboprostatic ligaments, although no long‐term data are available. Preservation of the urethral length yielded controversial outcomes. Concerning postoperative strategies, it is probably optimal to remove the catheter in a window between 4 and 7 days if clinically appropriate; however, more research in this regard is still required. Postoperative PFME (preoperative pelvic floor muscle exercise) appears to speed up the recovery of continence after RP. Conclusions: Conservative strategies to prevent PPUI include proper patient selection and PFME. Peroperative techniques have largely shown benefit in the short term. Postoperative complications and timing of trial without catheter can influence continence status. Future research initiatives must assess peroperative and postoperative measures, with longer‐term follow‐up. [ABSTRACT FROM AUTHOR]

Objective: To report the first prospective comparative analysis of robot‐assisted (RASP) vs open simple prostatectomy (OSP) for large prostate glands. Materials and Methods: We prospectively analysed 41 patients who underwent surgery for benign prostatic hyperplasia between 2014 and 2017 at one of two university institutions. Patients were grouped according to the procedure (OSP or RASP) and matched in terms of age, prostate volume, body mass index and prostate‐specific antigen level. The two groups were followed prospectively for 3 months, and their postoperative and functional outcomes were compared. Results: Six patients (40%) in the OSP and seven patients (27%) in the RASP arm of the study had preoperative urethral catheters as a result of relapsed urinary retention. The amount of blood loss during surgery was significantly lower in the RASP arm (539  vs 274 mL), but the operating time was significantly longer (134 vs 88 min). One patient in the RASP group experienced a Clavien–Dindo grade II complication, whereas in the OSP group, four patients experienced serious complications (27%); one patient had a bladder rupture (Grade III), one patient developed deep venous thrombosis (Grade II), and two patients required blood transfusions (one unit each; Grade II). Two patients (one from each group) experienced urinary retention after catheter removal that required a urethral catheter replacement. In the follow‐up period, there were significant and similar improvements in International Prostate Symptom Scores, uroflowmetry results and post‐void residual urine volume in both groups. Conclusion: The results showed that RASP provided similar functional outcomes to those of OSP, whilst maintaining a good (or even better) safety profile. Our results suggest that RASP is a viable, efficient and potentially superior alternative to the open procedure. [ABSTRACT FROM AUTHOR]

Wilson's disease (WD) is caused by the excessive accumulation of copper in the brain and liver, leading to death if not diagnosed early. WD shows its prevalence as white matter hyperintensity (WMH) in MRI scans. It is challenging and tedious to classify WD against controls when comparing visually, primarily due to subtle differences in WMH. This Letter presents a computer-aided design-based automated classification strategy that uses optimised transfer learning (TL) utilising two novel paradigms known as (i) MobileNet and (ii) the Visual Geometric Group-19 (VGG-19). Further, the authors benchmark TL systems against a machine learning (ML) paradigm. Using four-fold augmentation, VGG-19 is superior to MobileNet demonstrating accuracy and area under the curve (AUC) pairs as 95.46 ± 7.70%, 0.932 (p < 0.0001) and 86.87 ± 2.23%, 0.871 (p < 0.0001), respectively. Further, MobileNet and VGG-19 showed an improvement of 3.4 and 13.5%, respectively, when benchmarked against the ML-based soft classifier – Random Forest. [ABSTRACT FROM AUTHOR]

The article provides information on the liver atoll sign used to describe the appearance on ultrasound of the small islands of hyperplastic hepatocytes separated by normal parenchyma in nodular regenerative hyperplasia of the liver.

Aims: The injection of botulinum neurotoxin A (BTA) into the prostate represents a minimally invasive treatment in patients with lower urinary tract symptoms (LUTS) associated to benign prostatic hyperplasia (BPH). We evaluated the effectiveness of BTA in treating patients with BPH unresponsive to combined medical therapy (CMT), using urodynamic investigations. Methods: This is a randomized, placebo‐controlled, double blind trial. Twenty consecutive patients were randomly assigned to receive intraprostatic BTA injection (n = 10) or saline solution (SS) (n = 10). Patients in the intervention group (IG) received 200‐300 UI of BTA diluted in 6‐8 mL of SS and injected into the transitional zone. Patients in the control group (CG) were treated with SS alone. Primary endpoint was International Prostate Symptom Score (IPSS). Secondary endpoints were: maximum flow rate (Qmax), postvoid residual volume (PVR), maximum cystometric capacity (MCC), bladder outlet obstruction index (BOOI), safety, quality of life (QoL) score, and Patient Reported Outcome (PROs). Results: All patients in the IG reported subjective improvement starting after 1 month. At 3 months of follow‐up IPSS, QoL, PVR were reduced by 55,3% (P < 0.01), and 50% (P < 0.01), 80,6%, (P < 0.01), respectively. Qmax was increased by 68% (P < 0.01). MCC increased by 27% (P < 0.01) and BOOI decreased by 54% (P < 0.01). PROs analysis revealed that 90% of patients in the IG reported a subjective symptomatic relief and treatment satisfaction. No local or systemic side effects were observed in any group. Conclusions: These results indicated that intraprostatic BTA is safe and can improve LUTS and QoL in patients with BPH and unsatisfactory response to CMT. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the occurrence of severe urinary complications within 2 years of surgery in men undergoing either robot‐assisted radical prostatectomy (RARP), laparoscopic radical prostatectomy (LRP) or retropubic open radical prostatectomy (ORP). Patients and Methods: We conducted a population‐based cohort study in men who underwent RARP (n = 4 947), LRP (n = 5 479) or ORP (n = 6 873) between 2008 and 2012 in the English National Health Service (NHS) using national cancer registry records linked to Hospital Episodes Statistics, an administrative database of admissions to NHS hospitals. We identified the occurrence of any severe urinary or severe stricture‐related complication within 2 years of surgery using a validated tool. Multi‐level regression modelling was used to determine the association between the type of surgery and occurrence of complications, with adjustment for patient and surgical factors. Results: Men undergoing RARP were least likely to experience any urinary complication (10.5%) or a stricture‐related complication (3.3%) compared with those who had LRP (15.8% any or 5.7% stricture‐related) or ORP (19.1% any or 6.9% stricture‐related). The impact of the type of surgery on the occurrence of any urinary or stricture‐related complications remained statistically significant after adjustment for patient and surgical factors (P < 0.01). Conclusion: Men who underwent RARP had the lowest risk of developing severe urinary complications within 2 years of surgery. [ABSTRACT FROM AUTHOR]

Aim Vascular abnormalities present advantages and/or disadvantages for the patient undergoing surgery. The aims of this study were to define, classify and demonstrate the courses, and to assess the clinical value, of arterial and venous abnormalities in the central mesentery. Method We conducted a review of the anatomy of 340 patients planned for enrolment in the 'Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography' trial, 312 of whom were submitted to surgery. Vascular abnormalities were analysed in context with surgical notes and images. A meta-analysis of the literature was performed. Results Arterial Abnormalities were found in 28 (8.2%) of the 340 patients and were classified into the following three groups based on anticipated surgical difficulty: group 1, accessory or replaced arteries to solid organs [14 (4.1%)]; group 2, arterial shunts [11 (3.2%)] between the coeliac trunk and the superior mesenteric artery, which resulted in bleeding in three patients; and group 3, common stem abnormalities [3 (0.9%)]. Two groups of superior mesenteric vein abnormalities were noted. The first included morphological abnormalities in a single vein [4 (1.2%)]: aneurysm [1 (0.3%)]; and ring variants of principal tributaries [3 (0.9%)]. The second included double superior mesenteric vein trunks [31 (9.1%)]: genuine bifid [10 (2.9%)]; and pseudo bifid [21 (6.2%)]. The meta-analysis revealed 26 articles, including 10 series of anatomical dissections or angiographies [1970 cases with 205 (10.4%) arterial abnormalities] and 16 case reports, none of which described a clinical or surgical setting. Conclusion Vascular abnormalities occur frequently. Arterial abnormalities are a hazard when inadvertent injury occurs during surgery. Preoperative knowledge of a bifid superior mesenteric vein is useful. [ABSTRACT FROM AUTHOR]

Aim To compare the functional outcomes after laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RARP). Methods Between September 2008 and January 2016, 712 patients underwent radical prostatectomy (RP; 614 LRP and 98 RARP). Recovery of incontinence was evaluated through a 24-h pad test. Urinary and erectile function was evaluated using the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function-5. Follow-up interval was 1, 3, 6 and 12 months after the surgery. The propensity score matching was used to balance the preoperative characteristics. Results The recovery of incontinence was similar to the two groups at 6 and 12 months after the surgery. However, patients underwent RARP restored the continence sooner than those in the LRP group in 1 and 3 months after the surgery ( P < 0.001 and 0.001). For the multivariable analysis, the type of RP procedure was a uniquely meaningful contributing factor ( P = 0.001, HR = 1.925; 95% CI, 1.299-2.851). In the case of urinary function, the RARP groups showed a better IPSS score than LRP groups at the 1-, 3- and 6-month visits, respectively ( P = 0.008, 0.026, 0.001), and the RARP groups early improved compared with LRP groups at the 3-month visit in the case of erectile function ( P = 0.018). Conclusion The RARP tended toward getting back the urinary continence earlier than the LRP. In addition, urinary and erectile function recovered more quickly in the RARP group than in the LRP group. [ABSTRACT FROM AUTHOR]

Reply to Comment: MR Enhanced Otolaryngology Case-Based Learning - A Randomized Educational Study We thank Chytas et al. for the response to our article and highlighting some important points of consideration going forward.[[1]] The technological ecosystem of immersive technologies in which Mixed reality (MR) and Augmented reality (AR) exist is rapidly progressing.[3] With this, definitions and descriptions of novel technologies often evolve and are at constant risk of becoming outdated and misunderstood. It is quite correctly stated by Chytas et al. that avoiding work toward consensus definitions would potentially inhibit research into technology enhanced learning and continue to confuse the readership leading to slower diffusion of validated educational tools. [Extracted from the article]

To conduct a systematic review of the risks of short-term outcomes after major treatments for clinically localised prostate cancer. MEDLINE, EMBASE and the Cochrane Library were searched from 2004 to January 2013. Study arms that included ≥100 men with localised prostate cancer in receipt of surgery, radiotherapy or active surveillance and reported symptomatic and quality-of-life (QoL) data from 6 to 60 months after treatment were eligible. Data were extracted by one reviewer and checked by another. In all, 64 studies (80 treatment cohorts) were included. Most were single treatment cohorts from the USA or Europe. Radiotherapy was the most common treatment (40 cohorts, including 31 brachytherapy cohorts) followed by prostatectomy (39 cohorts), with only one active surveillance cohort. Most frequently measured symptoms were urinary, followed by sexual, and bowel; QoL was assessed in only 17 cohorts. Most studies used validated measures, although poor data reporting and differences between studies meant that it was not possible to pool data. Data on the precise impact of short-term symptomatic and QoL outcomes after treatment for localised prostate cancer are of insufficient quality for clear guidance to men about the risks to these aspects of their lives. It is important that future studies focus on collecting core outcomes through validated measures and comply with reporting guidelines, so that clear and accurate information can be derived for men considering screening or treatment for prostate cancer. [ABSTRACT FROM AUTHOR]

Aim Gate's glomerular filtration rate (gGFR) measured by 99mTc-DTPA renal dynamic imaging and estimated GFR (eGFR) estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation are two indexes used to evaluate renal function. However, little is known about whether gGFR can be used to accurately assess renal function in horseshoe kidney (HSK) patients with renal fusion anomalies. Methods Nineteen HSK patients (HSK group) diagnosed by renal imaging and 38 CKD patients with 'normal kidney shape' (non-HSK group) matched to the HSK patients in terms of gender, age and biochemical indicators at Chinese PLA General Hospital were enrolled in this study. Gender, age, serum total protein (TP), albumin (ALB), blood urea nitrogen (BUN), serum creatinine (Scr), gGFR and eGFR were recorded and analyzed using χ2 test, t-test, and Wilcoxon test which was presented as median(IQR). Results (1) There were no significant differences in gender, age, TP, ALB, BUN, Scr, or eGFR between these two groups. (2) In HSK patients, the renogram showed abnormal renal axis with the lower poles orientated medially. The timed uptake curve showed that the isotope excretion in the HSK group was slower than that in the non-HSK group. (3) For all HSK patients, gGFR was significantly lower than eGFR (range -12.52 mL/min per 1.73m2 to -93.18 mL/min per 1.73m2). There was no significant difference in eGFR between the HSK [96.42 (36.02) mL/min per 1.73 m2] and non-HSK groups [94.46 (33.00) mL/min per 1.73 m2]. The gGFR of the HSK group [41.18 (16.60) mL/min per 1.73m2] was much lower than that of the non-HSK group [86.42(26.40) mL/min per 1.73m2, P < 0.001] and the eGFR of the HSK group ( P < 0.001). The gGFR and eGFR of the non-HSK group were not significantly different. Conclusion gGFR measured by 99mTc-DTPA renal dynamic imaging is significantly lower than eGFR estimated by the CKD-EPI equation, which indicates that isotope renogram cannot accurately evaluate the GFR of HSK patients. [ABSTRACT FROM AUTHOR]

Objectives: To compare the outcomes of prostatic arterial embolization (PAE) in treating large (>80 mL) in comparison with medium-sized prostate glands (50-80 mL) to determine whether size affects the outcome of PAE. Patients and Methods: A total of 115 patients (mean age 71.5 years) diagnosed with lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) refractory to medical treatment underwent PAE. Group A (n = 64) included patients with a mean prostate volume of 129 mL; group B (n = 51) included patients with a mean prostate volume of 64 mL. PAE was performed using 100-lm particles. Follow-up was performed using the International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow rate (Qmax), post-void residual urine volume (PVR), the International Index of Erectile Function short form (IIEF-5), prostate-specific antigen (PSA) and prostate volume measured by magnetic resonance imaging at 1, 3 and 6 months, and every 6 months thereafter. Results: There were no significant differences between groups in baseline IPSS, QoL, Qmax, PVR, PSA level or IIEF-5 score. The technical success rate was 93.8% in group A and 96.8% in group B (P = 0.7). A total of 101 patients (55 patients in group A and 46 patients in group B) completed the mean (range) follow-up of 17 (12-33) months. Compared with baseline, there were significant improvements in IPSS, QoL, Qmax, prostate volume and PVR in both groups after PAE. The outcomes in group A were significantly better than in group B with regard to mean ± SD IPSS (-14 ± 6.5 vs -10.5 ± 5.5, respectively), Qmax (6.0 ± 1.5 vs 4.5 ± 1.0 mL/s, respectively), PVR (-80.0 ± 25.0 vs -60.0 ± 20.0 mL, respectively), prostate volume (-54.5 ± 18.0 mL [-42.3%] vs -18.5 ± 5.0 mL [-28.9%], respectively), and QoL score (-3.0 ± 1.5 vs -2.0 ± 1.0) with P values <0.05. The mean IIEF-5 score was not significantly different from baseline in both groups. No major complications were noted. Conclusions: We found that PAE is a safe and effective treatment method for patients with LUTS attributable to BPH. The clinical and imaging outcomes of PAE were better in patients with larger prostate glands than medium-sized ones. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy. Methods This was a prospective single-center, case-control study. A total of 40 consecutive patients with organ-confined prostate cancer were submitted to radical prostatectomy with the preservation of the muscular internal sphincter and the proximal urethra (group 1), and their outcomes were compared with those of 40 patients submitted to a standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7 and 30 days, and 3 and 12 months after removal of the catheter. Results Group 1 had a faster recovery of early continence than group 2 at day 3 (45% vs 22%; P = 0.029) and at day 7 (75% vs 50%; P = 0.018). Considering the number of pads, group 1 had a faster recovery of continence at 3, 7 and 30 days, and also had less incidence of severe incontinence. There was no statistically significant difference in terms of continence at 3 and 12 months among the two groups. Multivariate logistic regression analysis showed that surgical technique and young age were significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins. Conclusions Our modified technique of radical retropubic prostatectomy with preservation of the smooth muscular internal sphincter, as well as of the proximal urethra during bladder neck dissection, results in a significantly increased urinary continence at 3, 7 and 30 days after catheter removal, with a minor incidence of severe incontinence. The technique is also oncologically safe, and it does not increase the operative duration of the procedure. [ABSTRACT FROM AUTHOR]

Objective To report a novel technique for performing single-port transvesical laparoscopic radical prostatectomy ( STLRP) and to evaluate the oncological and functional outcomes in 16 patients with organ-confined prostate cancer., Patients and Methods In total, 16 consecutive patients with clinical stage T1-2a N0M0 were scheduled for STLRP, and their continence and erectile status were investigated preoperatively., The patients' mean age was 62 years, mean prostate volume 42 mL and mean prostate-specific antigen ( PSA) 7.5 ng/mL., The STLRP procedures were performed by a single surgeon, and all the operating procedures were conducted transvesically and laparoscopically., Intra-operative and postoperative complications, assessed according to the modified Clavien system, were recorded and peri-operative and functional outcome data were analysed., All patients were followed up for a minimum of 12 months postoperatively through PSA detection, daily pads, the International Index of Erectile Function ( IIEF)-6 score and urography., Results All of the 16 STLRP procedures were successfully completed. The mean (range) operation duration was 105 (75-180) min, and the mean (range) estimated blood loss was 130 (75-500) mL. No patients had positive surgical margins. Postoperative complications occurred in five patients, including three cases of urinary infection and two cases of haematuria (grade II). Catheters were removed after a mean (range) time of 11.2 (9-14) days with cystography. The mean (range) hospital stay was 12.7 (10-15) days., Of the 16 patients, 13 were immediately continent (0 pads/day), and three had mild incontinence (2-3 pads/day) after catheter removal. All patients were observed as continent 3 months postoperatively., In total, 10/16 and 12/16 patients achieved a satisfactory erection at 6 and 12 months follow-up postoperatively, respectively, with an IIEF-6 score ≥ 18., The mean postoperative PSA levels at 3, 6 and 12 months were 0.015 ng/mL, 0.017 ng/mL and 0.016 ng/mL, respectively. No patients were identified with biochemical recurrence in this series. No patients demonstrated vesico-urethral stricture during follow-up for 12-24 months., Conclusions We conclude that STLRP is technically feasible for patients with low-risk organ-confined prostate cancer and demonstrates promising functional outcomes regarding continence and potency. [ABSTRACT FROM AUTHOR]

Objectives To compare the efficacy and safety of transurethral enucleation and resection of the prostate ( TUERP) and transvesical prostatectomy ( TVP) for patients with benign prostatic hyperplasia ( BPH) and prostate volumes >80 mL., Patients and Methods A total of 100 patients with urodynamic obstruction and prostate volume >80 mL were prospectively randomized and enrolled in the study at a tertiary hospital., Patients underwent TVP or TUERP performed by one of two surgeons with experience of a large number of cases., All patients were preoperatively evaluated using patient age, prostate volume measurement, clinical characteristics of digital rectal examination, self-assessment using the International Prostate Symptom Scores ( IPSS) questionnaire, a quality-of-life ( QoL) questionnaire, maximum urinary flow rate ( Qmax), post-void residual urine volume ( PVR), urine analysis, blood sample analysis, including determination of prostate-specific antigen ( PSA) and haemoglobin concentration., All patients were assessed peri-operatively and postoperatively at 3 and 12 months. All complications were documented., Results Of 100 patients eligible to participate, 92 patients completed 12 months of follow-up., Patients who underwent TUERP had shorter catheterization times and hospital stays. Operation duration was not significantly different between the two surgical groups ( P = 0.107)., The resected adenoma weight in the TVP group was more than that in the TUERP group, but the difference was not significant ( P = 0.062)., There were no significant differences in IPSS, PVR, Qmax or QoL scores between the groups at 3 and 12 months. The patients in the TVP group appeared to have a better Qmax at 3 months, however, the difference was not significant ( P = 0.081)., Adverse events were similar in the two groups., Conclusion We found that TUERP had efficacy and safety equivalent to that of TVP for patients with BPH and prostate volume >80 mL. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? According to the EAU Guidelines 2012, large size benign prostatic hyperplasia ( BPH) cases (>80 mL) continue to have open prostatectomy as the first line treatment alternative, despite the substantial peri-operative morbidity and extended catheterization and convalescence periods related to this undoubtedly invasive approach. During the past two decades, holmium laser enucleation of the prostate was constantly described as a successful choice for this category of patients. According to rather numerous studies, the technique displayed superior results in terms of surgical safety and postoperative recovery compared with the open procedure. On the other hand, the concept of electrosurgical enucleation of the prostate, using either a monopolar or bipolar cutting current, materialized into several technical applications that eventually failed to gain general acknowledgement as reliable alternatives to the BPH transurethral approach., While keeping in mind the already proved advantage of enucleating substantial quantities of BPH tissue, bipolar plasma enucleation of the prostate was introduced as a novel endoscopic approach in cases of large prostates. The present trial represents the first prospective, medium-term, randomized comparison to be published of this innovative technique with standard open prostatectomy. Basically, the premises for a viable alternative relied on the practical advantages provided by the 'button' electrode, mainly the large surface creating the conditions for a fast enucleation process, continuous vaporization and concomitant haemostasis. Eventually, it was concluded that the plasma enucleation procedure distinguished itself as a successful treatment option in large BPH patients, characterized by good surgical efficiency, significantly reduced complications, faster postoperative recovery, similar prostatic tissue ablation capabilities and satisfactory follow-up results compared with the open technique. Most importantly, plasma-button enucleation patients benefited from a similar 12 months' outcome from the perspectives of symptom scores and voiding parameters when drawing a parallel with open surgery results, thus underlining the reliable viability of this type of endoscopic approach., Objectives To evaluate the viability of bipolar plasma enucleation of the prostate ( BPEP) by comparison with open transvesical prostatectomy ( OP) in cases of large prostates with regard to surgical efficacy and peri-operative morbidity., To compare the medium-term follow-up parameters specific for the two methods., Patients and Methods A total of 140 benign prostatic hyperplasia ( BPH) patients with prostate volume >80 mL, maximum flow rate ( Qmax) <10 mL/s and International Prostate Symptom Score ( IPSS) >19 were randomized in the two study arms., All cases were assessed preoperatively and at 1, 3, 6 and 12 months after surgery by IPSS, Qmax, quality of life score ( QoL) and post-voiding residual urinary volume ( PVR)., The prostate volume and prostate specific antigen ( PSA) level were measured at 6 and 12 months., Results The BPEP and OP techniques emphasized similar mean operating durations (91.4 vs 87.5 min) and resected tissue weights (108.3 vs 115.4 g)., The postoperative haematuria rate (2.9% vs 12.9%) as well as the mean haemoglobin drop (1.7 vs 3.1 g/ dL), catheterization period (1.5 vs 5.8 days) and hospital stay (2.1 vs 6.9 days) were significantly improved for BPEP., Recatheterization for acute urinary retention was more frequent in the OP group (8.6% vs 1.4%), while the rates of early irritative symptoms were similar for BPEP and OP (11.4% vs 7.1%)., During the follow-up period, no statistically significant difference was determined in terms of IPSS, Qmax, QoL, PVR, PSA level and postoperative prostate volume between the two series., Conclusions BPEP represents a promising endoscopic approach in large BPH cases, characterized by good surgical efficiency and similar BPH tissue removal capabilities compared with standard transvesical prostatectomy., BPEP patients benefited from significantly reduced complications, shorter convalescence and satisfactory follow-up symptom scores and voiding parameters. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Many patients are eligible for more than one treatment option for prostate cancer. In usual care, urologists have a large influence on the treatment choice. Decision aids, providing balanced information on the pros and cons of different treatment options, improve the match between patient preferences and treatment received., In men eligible for both surgery and external beam radiotherapy, treatment choice differed by hospital. Across the participating hospitals, the decision aid consistently led to fewer patients remaining undecided on their treatment preference and more patients choosing brachytherapy., Objectives To examine the treatment choice for localized prostate cancer in selected men who were eligible for both prostatectomy and radiotherapy., To examine whether increased patient participation, using a decision aid, affected the treatment choice., Patients and Methods From 2008 to 2011, 240 patients with localized prostate cancer were enrolled from three separate hospitals., They were selected to be eligible for both prostatectomy and external beam radiotherapy. Brachytherapy was a third option for about half of the patients., In this randomized controlled trial, patients were randomized to a group which only discussed their treatment with their specialist (usual care group) and a group which received additional information from a decision aid presented by a researcher (decision aid group). The decision aid was based on a literature review., Predictors of treatment choice were examined., Results Treatment choice was affected by the decision aid ( P = 0.03) and by the hospital of intake ( P < 0.001)., The decision aid led to more patients choosing brachytherapy ( P = 0.02) and fewer patients remaining undecided ( P < 0.05)., Prostatectomy remained the most frequently preferred treatment., Age, tumour characteristics or pretreatment urinary, bowel or erectile functioning did not affect the choice in this selected group., Patients choosing brachytherapy assigned more weight to convenience of the procedure and to maintaining erectile function., Conclusions Traditionally, patient characteristics differ between surgery and radiotherapy groups, but not in this selected group of patients., Men eligible for both prostatectomy and radiotherapy mostly preferred prostatectomy, and the treatment choice was influenced by the hospital they visited., Giving patients evidence-based information, by means of a decision aid, led to an increase in brachytherapy. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Standard monopolar transurethral resection of prostate ( TURP) remains the gold standard surgical treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Bipolar salin TURP offers rapid tissue removal and haemostasis during resection with better vision under saline irrigation while eliminating risk of TUR syndrome., Few prospective randomized studies have investigated the effect of bipolar and monopolar TURP on erectile function. The study found that bipolar saline TURP is a safe and effective procedure that is associated with a significantly shorter operating time, a smaller reduction in serum sodium levels and similar efficacy compared with conventional monopolar TURP., Objective To evaluate the outcomes of bipolar vs conventional monopolar transurethral resection of the prostate ( TURP) on urinary and erectile function., Material and Methods A total of 286 patients with benign prostatic hyperplasia ( BPH) were randomized to bipolar or monopolar conventional TURP treatment groups., Operative and early postoperative variables and complications were recorded and all patients were re-evaluated at 1, 3, 6 and 12 months after surgery using the International Prostate Symptom Score ( IPSS), uroflowmetry, post-void residual urine volume ( PVR) and the erectile function domain of the International Index of Erectile Function ( IIEF-ED)., A comparative evaluation of erectile function was performed on 188 preoperatively non-catheterized patients with regular sexual partners., Results The operating time was shorter in the bipolar TURP group. Postoperative bleeding and blood transfusion requirements did not significantly differ between the two groups. Sodium levels were significantly lower in the monopolar group than in the bipolar group., Transuretheral resection syndrome developed in two (1.4%) patients in the monopolar group. Both groups had similar and significantly improved IPSS values, maximum urinary flow rate values and PVR measurement., ED worsened in 32 (17.0%) patients, improved in 53 (28.2%) patients, and was unchanged in 103 (54.8%) patients. Changes in the IIEF scores during the follow-up period were similar between the bipolar and monopolar groups., Conclusion Bipolar TURP is a safe and effective procedure that is associated with a significantly shorter operating time, a smaller reduction in serum sodium levels and a similar efficacy compared with conventional monopolar TURP. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The open simple prostatectomy (OSP) is the 'gold standard' for high-volume prostate adenomas. It shows very good functional results despite its invasiveness. Minimally invasive approaches, e.g. laparoscopy or holmium laser enucleation of the prostate, have been 'tested' but none have proved a substitute for the OSP. The robot-assisted approach provides optimal functional results and is easy to perform for experienced robotic surgeons. Extending the indication of robotics to low-incidence pathologies can take advantage of the opportunity to 'see the procedure' using available information technology, e.g. Youtube™ that presents as an unexpectedly useful tool. OBJECTIVE To evaluate the outcome, feasibility and reproducibility of a robot-assisted (RA) approach for simple prostatectomy (SP) in cases of high-volume symptomatic benign prostatic hyperplasia (HVS-BPH)., PATIENTS AND METHODS In all, 35 consecutive patients underwent RASP for HVS-BPH using a previously described technique., The mean prostate volume on preoperative transrectal ultrasonography was 106.6 mL., All but two patients (with bladder calculi) had an adenoma volume of >65 mL and 27 (77.1%) >80 mL. Nine patients (25.7%) had an indwelling catheter., The mean International Prostate Symptom Score (IPSS) was 28., RESULTS The median operative duration was 180 min and the mean hospital stay was 3.17 days., The mean catheter duration was 7.4 days and discontinuous or continuous catheter irrigation was required in two and seven patients, respectively (25.1%)., In all, 10 patients (28.6%) had practically no blood loss. No patients had a transfusion., The mean postoperative peak urinary flow was 18.9 mL/s ( P < 0.001), while the mean IPSS was 7 ( P < 0.001)., For costs, while superficially RASP appeared more expensive than open SP (OSP), when considering the higher costs of hospitalisation for OSP, RASP was cheaper. Also, bipolar-TURP costs in patients with large-volume prostates had rather similar costs to RASP., CONCLUSIONS RASP is a feasible and reproducible procedure with outcome advantages when compared with the open or with other minimally invasive techniques (laser or laparoscopy). As a result, a RA approach is worth considering in cases of high-volume prostate adenomas., Extending the indication of the RA approach, to the SP, requires firstly that the surgeon be proficient in RA surgery and secondly that as the incidence rate of HVS-BPH is low, the surgeon has had the opportunity to 'see the procedure'. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH)., METHODS Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP)., Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry., The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort® laparoscopic system positioned in the bladder. The da Vinci S™ robotic operating system was docked through the GelPort® platform and enucleation was performed., Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded., RESULTS One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy., Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion., Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days., There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively., CONCLUSION The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 OBJECTIVE [ABSTRACT FROM AUTHOR]

OBJECTIVE To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot-assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well-described complication of ORP and may be partially attributable to technique. PATIENTS AND METHODS The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer-specific information, surgical data, and follow-up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan-Meier methods. RESULTS From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow-up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean ( SD ) age was 59.3 (6.80) years and 91% of men were Caucasian. D'Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP ( P = 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1-15) months after surgery. At 18 months after surgery, the BNC-free rate was 97% for ORP and 99% for RALP (log-rank P = 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC. CONCLUSIONS The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group. [ABSTRACT FROM AUTHOR]

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b OBJECTIVE To investigate and compare changes in the bladder function after radical prostatectomy (RP) and to correlate changes in subjective voiding symptoms with the observed changes in function. PATIENTS AND METHODS In 72 patients who had RP between 2003 and 2004, we serially evaluated urodynamic studies (UDS) before RP and at 3, 6 and 36 months afterward. The short-form International Continence Society- male symptom questionnaire was also repeated at corresponding periods. Changes in bladder contraction and storage function after RP were compared for changes in subjective symptoms. RESULTS On serial UDS, there were reductions in maximum cystometric capacity, maximum detrusor pressure and maximum urethral closure pressure (MUCP) at 3 months, after which all remained relatively unchanged. On the questionnaire, the voiding symptom domain score improved (8.04 to 4.82, P < 0.001) while the storage domain score significantly and progressively worsened, beginning from 3 months (2.25 to 3.78, P= 0.04), resulting in an unchanged overall urinary symptom-related quality of life at 3 years. The incidence of detrusor overactivity increased from 37.5% before RP, to 45.8% at 3 months and 51.4% at 3 years. At 3 years, a recurring postvoid residual urine volume was the cause of the deterioration in the voiding symptom domain score, while a prominent reduction in MUCP resulted in a deterioration in the storage symptom score. CONCLUSIONS There is a reduction in bladder capacity, detrusor and sphincteric activity immediately after RP, stabilizing thereafter but remaining significantly reduced at 3 years. Although voiding symptoms improved in most men, the significant deterioration in storage symptoms, which might be attributed to sphincteric incompetence in addition to increased detrusor overactivity, became a source of overall urinary bother in the long term. [ABSTRACT FROM AUTHOR]

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided. [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]

The article reports on the study which determines the physiologic characteristics of young men after cancer treatment which include the quality of life, self-esteem, and sexual function. It notes that young male cancer survivors who have androgen deficiency are reported to experience fatigue and impaired health status. It implies that testosterone is complex and appears to be dependent on a threshold level with no direct correlation.

OBJECTIVE To describe the surgical technique, objective and subjective medium-term outcomes of a novel continuous vesico-urethral anastomotic suture in open radical prostatectomy (ORP). PATIENTS AND METHODS A continuous anastomosis comprising separate anterior and posterior monofilament 3–0 polydioxanone sutures, with the bladder neck ‘parachuted’ down on to the urethral stump, was used in 39 consecutive patients. A cystogram was taken after ORP in the first 23 patients. The catheter was removed as soon as patients were fully mobile. A validated postal questionnaire to determine continence and its effect on quality of life was sent to all patients ≥3 months after ORP. RESULTS The mean follow-up was 18 months; there were no major complications. There was an insignificant or no leak in 91% of the patients who had a cystogram. Before discharge, 33 patients reported that they were continent, whilst five required a pad(s) for stress incontinence, and one was discharged with a catheter after failing the first catheter removal. Of the 95% who completed the questionnaire, 95% either did not leak urine, or only leaked a small amount; 84% of patients reported that leaking had a minimal effect on everyday life. No patients developed symptomatic urethral or bladder neck stricture/contracture. CONCLUSIONS Our technique of continuous anastomotic suturing for ORP is safe, reliable and well tolerated. Further randomized studies are warranted to compare the outcome with the standard interrupted vesico-urethral anastomosis. [ABSTRACT FROM AUTHOR]

OBJECTIVES To evaluate the difference in outcome of bladder neck contracture (BNC) and its causes between large groups of patients undergoing open radical prostatectomy (ORP) and robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS We analysed 200 consecutive RPs performed by one surgeon for prostate cancer, 100 by ORP and 100 by RALP, between March 2003 and September 2007. The operative techniques of bladder neck repair and urethro-vesical anastomosis were different. The ORP patients had a conventional stomatization and ‘racquet handle’ repair of the bladder if necessary, with mucosal eversion and a direct circular interrupted ‘end-to-end’ suture anastomosis between the bladder and urethra. The RALP patients had no bladder neck reconstruction or mucosal eversion and their anastomosis was by the continuous suture ‘parachute’ technique. RESULTS There was no BNC in the RALP group, whilst 9% of the ORP group developed a BNC ( P < 0.005). Apart from surgical technique, other variables, including patient age, previous transurethral resection of the prostate, Gleason score, T stage, urine infection rate, urinary leakage, blood loss, drain tube removal, anastomotic suture material, catheter type and catheter removal times were statistically comparable in both groups. CONCLUSION This series suggests that the major factor involved in the cause of bladder neck contracture after ORP, relates to the stomatization or ‘racquet handle’ bladder neck repair, and the end-to-end anastomosis between the urethra and stomatized bladder. Mucosal eversion might also contribute. Normal postoperative urinary leakage when the anastomotic apposition is good seems unlikely to be a significant aetiological factor in the development of BNC. Prolonged urinary leakage results from an anastomotic gap, which heals by second intention, thereby causing scarring and BNC. The RALP ‘parachute’ technique, which expands the anastomosis towards the bladder, appears to protect against BNC. Mucosal eversion is not necessary in the parachute repair. [ABSTRACT FROM AUTHOR]