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Background and Objectives: Radiation therapy (RT) plays a crucial role in managing prostate cancer, offering effective disease control and improving survival rates in both localized and recurrent cases. However, RT can lead to hemorrhagic cystitis, a significant late complication resulting in chronic morbidity and other health issues. This study aims to evaluate the real-world incidence of radiation-induced hemorrhagic cystitis requiring surgical intervention. Materials and Methods: This retrospective cohort study analyzed data from prostate cancer survivors treated for hematuria at our center between January 2014 and January 2024. Patients were included if cystoscopy identified radiation cystitis as the cause of hematuria. Descriptive statistics were used, and binomial logistic regression analyses with univariate and multivariate analysis were performed to identify risk factors for worse outcomes. Results: Fifty-two patients met the inclusion criteria. The estimated cumulative incidence at a median follow-up of 5.3 years was 4.5%. Among the participants, 21.2% required more than two transurethral bladder fulguration (TUBF) procedures, and 38.5% needed more than two hospital admissions for hematuria management. The median time to the first fulguration was 64 months. Blood transfusions were necessary in 53.8% of cases, and 38.5% required hyperbaric oxygen therapy. Ultimately, 5.8% of the patients underwent cystectomy. Univariate analysis identified ischemic heart disease (IHD) and antiplatelet therapy as significant risk factors (OR: 5.17 and 5.18, respectively), along with longer time to first fulguration (OR: 5.02). Multivariate analysis confirmed antiplatelet therapy (OR: 2.8, p = 0.05) and time to first TUBF (OR: 1.8, p = 0.02) as significant predictors of multiple procedures. Conclusions: Radiation cystitis remains a significant burden on prostate cancer survivors. Patients on antithrombotic agents, those with delayed initial presentations, and those who received radiation as salvage therapy are more likely to experience higher morbidity.

Treatment intensification with androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPi) have led to improved survival in advanced prostate cancer. However, ADT is linked to significant cardiovascular toxicity, and ARPi also negatively impacts cardiovascular health. Together with a higher prevalence of baseline cardiovascular risk factors reported among prostate cancer survivors at diagnosis, there is a pressing need to prioritise and optimise cardiovascular health in this population. Firstly, While no dedicated cardiovascular toxicity risk calculators are available, other tools such as SCORE2 can be used for baseline cardiovascular risk assessment. Next, selected patients on combination therapy may benefit from de-escalation of ADT to minimise its toxicities while maintaining cancer control. These patients can be characterised by an exceptional PSA response to hormonal treatment, favourable disease characteristics and competing comorbidities that warrant a less aggressive treatment regime. In addition, emerging molecular and genomic biomarkers hold the potential to identify patients who are suited for a de-escalated treatment approach either with ADT or with ARPi. One such biomarker is AR-V7 splice variant that predicts resistance to ARPi. Lastly, optimization of modifiable cardiovascular risk factors for patients through a coherent framework (ABCDE) and exercise therapy is equally important. This article aims to comprehensively review the cardiovascular impact of hormonal manipulation in metastatic hormone-sensitive prostate cancer, propose overarching strategies to mitigate cardiovascular toxicity associated with hormonal treatment, and, most importantly, raise awareness about the detrimental cardiovascular effects inherent in our current management strategies involving hormonal agents.

Background: Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) can detect multiparametric magnetic resonance imaging (mpMRI)-invisible prostate tumours and improve the sensitivity of detection of prostate cancer (PCa) in comparison to mpMRI alone. Numerous risk calculators have been validated as tools for stratification of men at risk of being diagnosed with clinically significant (cs)PCa. Objective: To develop a novel risk calculator using clinical parameters and imaging parameters from mpMRI and PSMA PET/CT in a cohort of patients undergoing mpMRI and PSMA PET/CT before biopsy. Design, setting, and participants: A total of 291 men from the PRIMARY prospective trial underwent mpMRI and PSMA PET/CT before transperineal prostate biopsy with sampling of systematic and targeted cores. Outcome measurements and statistical analysis: Novel risk calculators were developed using multivariable logistic regression analysis to predict detection of overall PCa (International Society of Urological Pathology grade group [GG] ≥1) and csPCa (GG ≥2). The risk calculators were then compared with the European Randomised Study of Screening for Prostate Cancer risk calculator incorporating mpMRI (ERSPC-MRI). Resampling methods were used to evaluate the discrimination and calibration of the risk calculators and to perform decision curve analysis. Results and limitations: Age, prostate-specific antigen, prostate volume, and mpMRI Prostate Imaging-Reporting and Data System scores were included in the MRI risk calculator, resulting in area under the receiver operating characteristic curve (AUC) values of 0.791 for overall PCa (GG ≥1) and 0.812 for csPCa (GG ≥2). Addition of the maximum standardised uptake value (SUVmax) on PSMA PET/CT for the prostate lesion, and of SUVmax for the mpMRI lesions for the MRI-PSMA risk calculator resulted in AUCs of 0.831 for overall PCa and 0.876 for csPCa (≥ISUP2).The ERSPC-MRI risk calculator had AUCs of 0.758 (p = 0.02) for overall PCa and 0.805 (p = 0.001) for csPCa. Both the MRI and MRI-PSMA risk calculators were superior to the ERSPC-MRI for both overall PCa and csPCa. Conclusions: These novel risk calculators incorporate clinical and radiological parameters for stratification of men at risk of csPCa. The risk calculator including PSMA PET/CT data is superior to a calculator incorporating mpMRI data alone. Patient summary: We evaluated a new risk calculator that uses clinical information and results from two types of scan to predict the risk of clinically significant prostate cancer on prostate biopsy. This risk model can guide patients and clinicians in shared decision-making and may help in avoiding unnecessary prostate biopsies.

Introduction: We describe a novel creation of a triangular extra-peritoneal space bounded by the lateral abdominal wall laterally, peritoneal reflection medially and inferior epigastric vessels distally (the LAPE pouch) that serves as an ideal entrapment pouch for specimen storage in TEP-RLRP. Patients and methodology: 50 consecutive patients underwent TEP-RLRP with the creation of the LAPE pouch for specimen storage. Inclusion criteria for TEP-RLRP were: (1) BMI ≤35 kg/m2, and (2) MRI prostate volume of ≤80 ml. Patient's demographics, intraoperative data (LAPE creation time, blood loss) and post-operative complications were analyzed. The step-by-step technique of LAPE pouch creation is as follows: (1) creation of extra-peritoneal space; (2) identification of key anatomical boundaries; (3) blunt dissection to create the LAPE pouch; (4) the fourth robotic port insertion at the tip of the LAPE triangular. Results: The mean age of patients was 66 years (51–77), mean BMI of 24.6 kg/m2 (19.8–34.8), mean PSA of 7.9 ng/ml (1.4–18), and mean MRI-measured prostate volume of 45.1 ml (20–80). Mean dissection time for LAPE pouch was 1.4 min (1.0–3.1). All specimens were successfully placed in the pouch with only one (2%) specimen displacement after placement intraoperatively. There were no complications because of LAPE pouch creation or use. Mean final prostate size corresponds well with MRI-measured prostate volume (47.9 gram vs 45.1 ml). Conclusions: This study presents a novel, safe and easy technique in creating an additional triangular extra-peritoneal space that overcome the pitfall of TEP RLRP in specimen storage.

The COVID-19 global pandemic has prompted educators in universities to reconsider their teaching methods, mainly due to the social distancing measures imposed within the classroom settings. On the other hand, the growing importance of continuing education opportunities for adult learners after graduation has seen the need to transform traditional teaching modes that primarily depend on face-to-face interaction into virtual modes, which are deemed more time- and cost-efficient. These major shifts in social and economic developments have a significant impact on the evolution of curriculum planning in higher education. Education that has scientific inquiry components inevitably comes into question, as conventional beliefs that experiments should be hands-on and will not be as effective if conducted virtually cast doubts on the move to the online space. This paper discusses the background of an impending shift in a university's approach to more online-based laboratory classes in an immunology course, as well as the exploration of the potential of conducting online laboratory experiments based on student perceptions.

Background and objective Patients with neuromuscular disease are often treated with home noninvasive ventilation (NIV) with devices capable of remote patient monitoring. We sought to determine whether long-term NIV data could provide insight into the effectiveness of ventilation over time. Methods We abstracted available longitudinal data for adults with neuromuscular disease in monthly increments from first available to most recent. Generalised linear mixed-effects modelling with subject-level random effects was used to evaluate trajectories over time. Results 1799 months of data across 85 individuals (median age 61, interquartile range (IQR) 46–71 years; 44% female; 49% amyotrophic lateral sclerosis (ALS)) were analysed, with a median (IQR) of 17 (8–35) months per individual. Over time, tidal volume increased and respiratory rate decreased. Dynamic respiratory system compliance decreased, accompanied by increased pressure support. Compared to volume-assured mode, fixed-pressure modes were associated with lower initial tidal volume, higher respiratory rate and lower pressures, which did not fully equalise with volume-assured mode over time. Compared with non-ALS patients, those with ALS had lower initial pressure support, but faster increases in pressure support over time, and ALS was associated wtih a more robust increase in respiratory rate in response to low tidal volume. Nonsurvivors did not differ from survivors in ventilatory trajectories over time, but did exhibit decreasing NIV use prior to death, in contrast with stable use in survivors. Conclusion NIV keeps breathing patterns stable over time, but support needs are dynamic and influenced by diagnosis and ventilation mode. Mortality is preceded by decreased NIV use rather than inadequate support during use.

Purpose: To perform a retrospective review of the clinicopathological features of patients with conventional and non-conventional renal cell carcinoma (cRCC and ncRCC). Materials and Methods: A large prospectively maintained uro-oncological registry was accessed to extract clinicopathological data of patients diagnosed with renal tumors who subsequently underwent nephrectomy from 1990–2019. Demographics and operative parameters were extracted. Analyses of overall survival (OS) and cancer-specific survival (CSS) were performed using the Kaplan–Meier method. Cox proportional-hazards analysis was used to identify risk factors which influenced survival. Results: There were a total of 1,686 consecutive nephrectomies which was retrieved, with 1,286 cRCC and 400 ncRCC. The commonest ncRCC subtypes were papillary (n=198, 11.7%), clear cell papillary (n=50, 3.0%) and chromophobe (n=49, 2.9%) RCC. Kaplan–Meier estimates of OS were higher in cRCC (0.74; 95% confidence interval [CI], 0.71–0.78) than ncRCC (hazard ratio, 1.47; 95% CI, 1.16–1.87). Among individual subtypes, chromophobe RCC had the highest 5-year OS (0.90; 95% CI, 0.79–1.0). Among ncRCC subtypes, acquired cystic RCC demonstrated the highest association with end-stage renal failure and hypertension, with the highest CSS. MiT family translocation RCC had the youngest mean age at presentation (45.6±12.8 y) and excellent CSS. Factors associated with increased OS in the entire cohort included shorter operative time, partial nephrectomy and lower tumor stages. Conclusions: This study provides a comprehensive contemporary overview of ncRCCs which are yet poorly characterized, in comparison to cRCCs. Data from this study would contribute towards tailored patient counseling and healthcare resource planning.

Introduction: Reconstructive techniques for ureteric strictures can compromise the blood supply of an anomalous ureter with distorted vasculature. Current approach of dismembering the vesicoureteric junction (VUJ) and re-implantation of ureter may compromise the vasculature of the remnant distal ureter and consequently the anastomosis. The need to fully mobilise distal ureteric segment by dissection may lead to complications such as ureteric aperistalsis, anastomotic stricture and pelvic hematoma requiring re-operation. In this report we aim to present a novel modified technique to the side-to-side VU anastomosis with emphasis on maximum vasculature-preserving dissection of the distal ureter and the incorporation of ureteric tapering. Patient and Surgical Procedure: A 57 year-old female patient has a history of congenital left mega-ureter who presented with progressive left flank pain of about 6-month duration. Pre-operative retrograde pyelogram showed a short segment VUJ stricture. The robotic-assisted laparoscopic side-to-side VU anastomosis technique is as follows: (1) five-port configuration triangulating to the left pelvis (2) Dissection limited to the anterior aspect of the mid-distal ureter with the strictured distal ureter and the VUJ left intact (3) Side-to-side anastomosis between the medial ureteric wall proximal to the strictured segment and the left lateral bladder wall (4) Tapering of the dilated ureter. Results: The operative time was 3 hours with blood loss of less than 100 mls. The patient was discharged uneventful on post-operative day-2 (POD-2) and urinary catheter was removed on POD-7. Retrograde pyelogram and ureteroscopy at 6 weeks post-operatively confirmed patency of the neoureterocystostomy and tapered ureter, with marked improvement of pelvicalyceal dilatation and prompt drainage of contrast. There was no complications reported and the patient had resolution of symptoms post-operatively. Conclusion: In this report, a novel robotic-assisted laparoscopic side-to-side VU anastomosis technique with ureteric tapering was illustrated in the management of a patient with a congenital obstructed mega-ureter. The technique emphasises maximum preservation of ureteric vasculature by minimising ureteric dissection, with tapering of the grossly redundant dilated mega-ureter which improves urinary drainage while minimising urinary stasis.

Penile squamous cell carcinoma (SCC) is a rare malignancy, which is known to invade local inguinal lymph nodes prior to progressing to the pelvis. Dynamic sentinel lymph node biopsy (DSLNB) is a standard for the minimally invasive assessment of lymphadenopathy in patients with subclinical groin metastasis. Hybrid 99mTc Single-Photon Emission Computed Tomography (SPECT-CT) has been shown to increase the accuracy of identifying first draining “sentinel” nodes (SN). Unilateral inguinal visualization on SPECT-CT is a rare presentation, which may increase the likelihood of a false negative SN biopsy. Retrospective analysis from three-penile cancer uro-oncologists in Melbourne, Australia identified 78 groins undergoing DSLNB for intermediate/high risk primary disease. Unilateral SPECT-CT results were observed in four patients suggesting a functional pattern of lymph diversion. Analysis confirmed malignancy (n = 2), sarcoidosis (n = 1), and evidence of local inflammation in SPECT-CT negative groins. Findings re-iterate the role of SPECT-CT a pre-operative adjunct. Experienced multimodal groin assessment using palpation, SPECT-CT, lymphoscintigraphy, and blue dye tracking remains paramount. Unilateral SN on pre-operative SPECT-CT in men with intermediate/high-risk penile SCC should elicit a higher degree of clinical suspicion. We recommend a low threshold for recommending radical inguinal lymph node dissection (ILND) for groins refractory to minimally invasive assessment.

Introduction and objectives: Centrally located renal tumours pose significant challenges for partial nephrectomy. We describe our technique for robotic-assisted partial nephrectomy (RAPN) for hilar tumour resection and report our outcomes, comparing hilar vs non-hilar tumours. Methods: Our single surgeon series consists of 302 cases, including 22 hilar masses. Steps for resection are described. Keys to a successful outcome include careful pre-planning, meticulous hilar dissection, and close tumour resection to avoid injuring uninvolved sinus structures. Resection then leaves a unique defect precluding closure in the usual manner. We propose three layers; individual ligation of larger vessels, continuous suture of the corticomedullary junction, then use of adjunct haemostatic agents such as SURGICEL® bolsters for cortical compression. Results: The median age of patients with hilar and non-hilar tumours were similar (59 years vs 60.5 years). Hilar tumours were significantly smaller (28.3 ± 7.2 mm vs 34.8 ± 16.0 mm, p = 0.03) and had higher median nephrometry scores (8 vs 7, p = 0.01). Peri-operative outcomes were similar between the 2 groups for operative duration (133.2 ± 33.2mins vs 129.5 ± 33.8mins, p = 0.31) with a trend towards less blood loss (115.5 ± 185.6cc vs 122.5 ± 158.1cc, p = 0.42) and longer warm ischaemia time (22.3 ± 9.9mins vs 18.6 ± 6.5mins, p = 0.01) for hilar tumours. Median length of stay was similar at 3 days (hilar IQR 2–3.5 days, non-hilar IQR 2–4 days). No cases converted to open or radical nephrectomy. Malignant tumours were more common for non-hilar group (86.3% vs 63.6%, p = 0.01), while benign histology was significantly more common in hilar masses (OR 3.6, p

The morphometry of the hip and pelvis can be evaluated in native radiographs. Artificial-intelligence-assisted analyses provide objective, accurate, and reproducible results. This study investigates the performance of an artificial intelligence (AI)-based software using deep learning algorithms to measure radiological parameters that identify femoroacetabular impingement and hip dysplasia. Sixty-two radiographs (124 hips) were manually evaluated by three observers and fully automated analyses were performed by an AI-driven software (HIPPO™, ImageBiopsy Lab, Vienna, Austria). We compared the performance of the three human readers with the HIPPO™ using a Bayesian mixed model. For this purpose, we used the absolute deviation from the median ratings of all readers and HIPPO™. Our results indicate a high probability that the AI-driven software ranks better than at least one manual reader for the majority of outcome measures. Hence, fully automated analyses could provide reproducible results and facilitate identifying radiographic signs of hip disorders.

Artificial intelligence (AI) in medicine is a rapidly growing field. In orthopedics, the clinical implementations of AI have not yet reached their full potential. Deep learning algorithms have shown promising results in computed radiographs for fracture detection, classification of OA, bone age, as well as automated measurements of the lower extremities. Studies investigating the performance of AI compared to trained human readers often show equal or better results, although human validation is indispensable at the current standards. The objective of this narrative review is to give an overview of AI in medicine and summarize the current applications of AI in orthopedic radiography imaging. Due to the different AI software and study design, it is difficult to find a clear structure in this field. To produce more homogeneous studies, open-source access to AI software codes and a consensus on study design should be aimed for.

Objective Primary objectives: to investigate the central neurobiological effects (using MRI) of physical exercise in individuals with chronic pain. Secondary objectives: (1) to investigate the associations between central changes and clinical outcomes and (2) to investigate whether different types and dosages of physical exercise exert different central changes.Design Systematic review searching four electronic databases up to September 2018: AMED, CINAHL, Embase and MEDLINE. Two reviewers independently assessed the methodological quality of included studies using the Cochrane Collaboration’s Risk of Bias in Non-Randomised Studies-I tool. A standardised extraction table was used for data extraction, which was performed by two reviewers.Interventions Studies reporting any physical exercise intervention in any chronic musculoskeletal pain condition were included. Eligibility of 4011 records was screened independently by two reviewers, and four studies were included in the review.Primary and secondary outcome measures Primary outcome: any brain outcome assessed with any MR technique. Secondary outcomes: any self-reported clinical outcomes, and type and dosage of the exercise intervention.Results All four studies had high risk of bias. There was heterogeneity between the brain areas studied and the types of exercise interventions delivered. All studies reported functional MRI changes in various brain areas following an exercise intervention. Insufficient data were available to conduct a meta-analysis or to answer the secondary aims.Conclusions Only a limited number of studies were available and all were at high risk of bias. None of the studies was randomised or included blinded assessment. Exercise may exert effects on brain neurobiology in people with chronic pain. Due to the high risk of bias, future studies should use a randomised study design. Investigation of morphological brain changes could be included.PROSPERO registration number CRD42018108179.

Background: While endourological approaches remained the predominant surgical modes for treating nephrolithiasis, robotic assisted surgery has emerged as an alternative approach in managing complex renal stone. The indications include failed former approaches, aberrant renal anatomy, unfavorable stone location or concurrent renal pathology. Objective: To describe our surgical technique of Robotic assisted Anatrophic Nephrolithotomy (RAN) in managing complex renal stone Design, setting and participants: We described a case of RAN for complex right complete staghorn calculi. This is a 41 year old gentleman who presented with extensive bilateral renal, ureteric and bladder calculi. He had undergone multiple PCNL, RIRS and cystolitholapaxy for removal of the left renal, ureteric and bladder calculi. RAN was offered for his right complete staghorn calculi. Surgical procedure: Ureteric stenting was first performed. The patient was then repositioned in standard left lateral position. The 4-port Da Vinci Si System was used. 2 additional laparoscopic ports were placed for assistance and liver retraction. The key steps in RAN were as followed: 1. Colonic mobilization and hilar dissection 2. Renal mobilization and scoring 3. Vascular clamp and Anatrophic Nephrolithotomy 4. Renorrhaphy and Nephropexy. Outcome measurements and statistical analysis: Intraoperative and postoperative clinical outcomes were recorded. Results and limitations: The operating time was 190 min and blood loss was 150 ml. The warm ischemic time was 28 min. There was no peri‑operative complications and patient was discharged on post-operative day 3. Renal function remained normal post-operatively. Post-operative radiograph showed >90% stone clearance and the ureteric stent was removed on day 14. Stone analysis revealed calcium oxalate. Patient was diagnosed with primary hyperparathyroidism and managed separately after. Conclusion: Robotic assisted surgery serves as an additional armamentarium in managing complex renal stone. Comparable stone clearance can be achieved while reaping benefits of minimally invasive surgery.

ObjectiveTo evaluate the incidence and management of local and systemic complications afflicting patients with de novo metastatic prostate cancer (mPCa) in Singapore.DesignRetrospective analysis of a large prospective Uro-oncology registry of mPCa.SettingThis study is carried out in a tertiary hospital in Singapore.ParticipantsWe reviewed our institution’s prospectively maintained database of 685 patients with mPCa over a 20-year period (1995–2014). Patients with non-mPCa or those progressed to metastatic disease after previous curative local treatments were excluded.Primary and secondary outcome measuresThe primary outcome was to evaluate the systemic and local morbidity rates associated with mPCa. Local complication was defined as the need for palliative procedures to relieve urinary obstruction, worsening renal function or refractory haematuria, while systemic complication was related to radiographic evidence of skeletal-related pathological fractures. Secondary outcomes analysed were the management and overall survival patterns over 20 years.Results237 (34.6%) patients required local palliative treatments. 88 (12.8%) patients presented with acute urinary retention, 23 patients (9.7%) required repetitive local palliative treatments. On multivariate analyses, prostate-specific antigen >100 (p=0.02) and prostate volume >50 g (p=0.03) were independent prognostic factors for significant obstruction requiring palliative procedures. 118 (17.2%) patients developed skeletal fractures, with poor Eastern Cooperative Oncology Group Performance (ECOG) status (p=0.01) and high volume bone metastasis (p

Despite antiretroviral therapy human immunodeficiency virus type-1 (HIV-1) infection results in neuroinflammation of the central nervous system that can cause HIV-associated neurocognitive disorders (HAND). The molecular mechanisms involved in the development of HAND are unclear, however, they are likely due to both direct and indirect consequences of HIV-1 infection and inflammation of the central nervous system. Additionally, opioid abuse in infected individuals has the potential to exacerbate HIV-comorbidities, such as HAND. Although restricted for productive HIV replication, astrocytes (comprising 40-70% of all brain cells) likely play a significant role in neuropathogenesis in infected individuals due to the production and response of viral proteins. The HIV-1 protein Tat is critical for viral transcription, causes neuroinflammation, and can be secreted from infected cells to affect uninfected bystander cells. The Wnt/β-catenin signaling cascade plays an integral role in restricting HIV-1 infection in part by negatively regulating HIV-1 Tat function. Conversely, Tat can overcome this negative regulation and inhibit β-catenin signaling by sequestering the critical transcription factor TCF-4 from binding to β-catenin. Here, we aimed to explore how opiate exposure affects Tat-mediated suppression of β-catenin in astrocytes and the downstream modulation of neuroinflammatory genes. We observed that morphine can potentiate Tat suppression of β-catenin activity in human astrocytes. In contrast, Tat mutants deficient in secretion, and lacking neurotoxic effects, do not affect β-catenin activity in the presence or absence of morphine. Finally, morphine treatment of astrocytes was sufficient to reduce the expression of genes involved in neuroinflammation. Examining the molecular mechanisms of how HIV-1 infection and opiate exposure exacerbate neuroinflammation may help us inform or predict disease progression prior to HAND development.

Purpose: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, and 20% of patients eventually require nephrectomies due to compressive symptoms or renal-related complications. Traditionally, nephrectomies were performed via the open approach in view of space constraints. We evaluate our institution's outcomes for laparoscopic nephrectomy (LN) for ADPKD. Materials and Methods: We retrospectively reviewed 33 patients with ADPKD who underwent nephrectomies from November 2005 to December 2016 at a tertiary institution. Preoperative kidney volume was calculated via the ellipsoid method by using computed tomography scan. Results: The median age was 51.0 years (interquartile range [IQR], 44.5–56.0 years). Sixteen patients (48.5%) underwent open nephrectomy (ON), 15 patients (45.5%) had LNs, and 2 patients (6.1%) had laparoscopic converted to ON due to dense adhesions. Thirteen patients had bilateral while 18 patients had unilateral nephrectomies. Median kidney volume in the open group was 1,042 cm3 (IQR, 753–2,365 cm3) versus 899 cm3 (IQR, 482–1,914 cm3) in the laparoscopy group and did not differ significantly. The operative time was comparable between both groups. Patients who underwent LN had lesser blood loss (350 mL vs. 650 mL; 95% confidence interval [CI], 1.822–3.533; p=0.016) and shorter length of hospital stay (4.0 days vs. 6.5 days; 95% CI, 1.445–5.755; p=0.001) compared to patients who underwent ON. Both groups had similar low morbidity rate and no mortality.

Objective: Active surveillance (AS) offers a strategy to reduce overtreatment and now is a widely accepted treatment option for low-risk prostate cancer. An ideal tool for risk-stratification would detect aggressive cancers and exclude such men from taking up AS in the first place. We evaluate if a combination of transperineal template biopsy with magnetic resonance imaging (MRI)-targeted biopsy identifies significant prostate cancer amongst men initially diagnosed with low-risk prostate cancer. Methods: This prospective, single-blinded study included men with low-risk prostate cancer (D'Amico's Criteria) diagnosed on conventional transrectal ultrasound-guided biopsy. Patients first underwent multiparametric MRI of the prostate ≥6 weeks after initial biopsy. Each suspicious lesion is mapped and assigned a Prostate Imaging Reporting and Data System (PIRADS) score. Template biopsy is first performed with the surgeon blinded to MRI findings followed by MRI-targeted biopsy using a robotic transperineal biopsy platform. Results: The age of the 19 men included is 65.4 ± 4.9 years (mean ± SD). Prostate specific antigen (PSA) at diagnosis and at the time of transperineal biopsy were comparable (7.3 ± 1.7 ng/mL and 7.0 ± 1.8 ng/mL, p = 0.67), so were prostate volumes (34.2 ± 8.9 mL and 32.1 ± 13.4 mL, p = 0.28). MRI-targeted biopsy had a higher percentage of cancer detection per core compared to template biopsy (11.7% vs. 6.5%, p = 0.02), this was more than 3 times superior for Gleason 7 disease (5.9% vs. 1.6%, p

Objective: Caudal block provides satisfactory postoperative pain relief in lower abdominal operations. This pilot study explores its safety and effect on postoperative pain control in patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP). Methods: From 2013 to 2014, 40 consecutive patients were randomized into two groups — one received caudal block using ropivacaine immediately after operation, the other received standard analgesia. Primary outcome measure was pain score based on 11-point Likert scale (0–10) recorded at recovery room, and at 6, 12, 24, 48, and 72 h after operation. All analgesic requirements, opioid-related adverse events and time to passage of flatus were examined. Results: Mean age of the two groups was similar (60.4 vs. 62.3 years, p = 0.33), as was American Society of Anaesthesiologists (ASA) class, body mass index (BMI) and operation times. No significant difference in median pain scores was reported in recovery room (2 vs. 3, p = 0.34), and at 6 h (2 vs. 2, p = 0.94), 12 h (0 vs. 0, p = 0.62), 24 h (1 vs. 0, p = 0.58), 48 h (1 vs. 0, p = 0.36) and 72 h (0 vs. 0, p = 0.78) postoperatively between control and caudal block groups, respectively. There was a higher mean opioid usage in the caudal block group which was not statistically significant. Although this was statistically insignificant while no significant difference in mean paracetamol usage was observed postoperatively. Median time to passage of flatus was similar (2.0 vs. 2.0 days, p = 0.97). There was one case of superficial wound infection and no opioid-related adverse events observed. Hospital stay was similar in both groups (2.5 vs. 2.5 days, p = 0.96). Conclusion: Although a safe modality, caudal block in post RARP patients does not seem to improve pain control nor reduce analgesia requirements. Keywords: Caudal block, Robotic radical prostatectomy, Post-operative pain, Analgesia, Opioid

Objectives The purpose of this systematic review is to identify and synthesise studies evaluating performance-based functional outcome measures designed to evaluate the functional abilities of patients with neck pain.Design Systematic review.Data sources A literature search using PubMed, Scopus, CINAHL, EMBASE, COCHRANE, Google Scholar and a citation mapping strategy was conducted until July 2019.Eligibility criteria More than half of the study’s patient population had neck pain or a musculoskeletal neck disorder and completed a functional-based test. Clinimetric properties of at least one performance-based functional tests were reported. Both traumatic and non-traumatic origins of neck pain were considered.Data extraction and synthesis Relevant data were then extracted from selected articles using an extraction guide. Selected articles were appraised using the Quality Appraisal for Clinical Measurement Research Reports Evaluation Form (QACMRR).Results The search obtained 12 articles which reported on four outcome measures (functional capacity evaluations (FCE), Baltimore Therapeutic Equipment Work Simulator II (BTEWS II), Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA)) and a physiotherapy test package, to assess the functional abilities in patients with mechanical neck pain. Of the selected papers: one reports content validity, five construct validity, four reliability, one sensitivity to change and one both reliability and construct validity. QACMRR scores ranged from 68% to 95%.Conclusions This review found very good quality evidence that the FIT-HaNSA has excellent inter and intra-rater reliability and very weak to weak convergent validity. Excellent quality evidence of fair test-retest reliability, weak convergent validity and very weak known groups validity for the BTEWS II test was found. Good to excellent quality evidence exists that an FCE battery has poor to excellent reliability and very weak to strong validity. Good to excellent quality of weak to strong validity and trivial to strong effect sizes were found for a physiotherapy test package.Prospero registration number CRD42018112358

Objective The purpose of this systematic review was to critically appraise and synthesise the psychometric properties of Global Rating of Change (GROC) scales for assessment of patients with neck pain.Design Systematic review.Data sources A search was performed in four databases (MEDLINE, EMBASE, CINAHL, SCOPUS) until February 2019.Data extraction and synthesis Eligible articles were appraised using Consensus-based Standards for the selection of health Measurement Instruments checklist and the Quality Appraisal for Clinical Measurement Research Reports Evaluation Form.Results The search obtained 16 eligible studies and included in total 1533 patients with neck pain. Test–retest reliability of global perceived effect (GPE) was very high (intraclass correlation coefficient=0.80 to 0.92) for patients with whiplash. Pooled data of Pearson’s r indicated that GROC scores were moderately correlated with neck disability change scores (0.53, 95% CI: 0.47 to 0.59). Pooled data of Spearman’s correlations indicated that GROC scores were moderately correlated with neck disability change scores (0.56, 95% CI: 0.41 to 0.68).Conclusions This study found excellent quality evidence of very good-to-excellent test–retest reliability of GPE for patients with whiplash-associated disorders. Evidence from very good-to-excellent quality studies found that GROC scores are moderately correlated to an external criterion patient-reported outcome measure evaluated pre-post treatment in patients with neck pain. No studies were found that addressed the optimal form of GROC scales for patients with neck disorders or compared the GROC to other options for single-item global assessment.PROSPERO registration number CRD42018117874.

Background: Vascular extension of Renal Cell Carcinoma (RCC) occurs in 4–10%. The most effective option is aggressive surgery, with radical nephrectomy and IVC thrombectomy, with reasonably good outcomes of 5-year survival rates ranging from 32% to 64%. Traditionally performed via open approach, newer studies have shown promising outcomes with robotic surgeries. However, laparoscopic techniques remained anecdotal. Objective: To describe our surgical technique of laparoscopic radical nephrectomy (LRN) and IVC thrombectomy and report its safety and intermediate outcomes. Design, setting and participants: We retrospectively reviewed 17 patients who underwent LRN and IVC thrombectomy between Jan 2014 to Oct 2016 across 3 tertiary institutions. Surgical procedure: Transperitoneal approach was performed in all cases. Limited IVC mobilisation is achievable in level I and mobile IVC thrombus. Higher thrombus levels required complete IVC exploration. The IVC defect is closed primarily with continuous laparoscopic stitching. Outcome measurements and statistical analysis: Intraoperative and postoperative clinical outcomes were recorded. A descriptive statistical analysis was performed. Results and limitations: Four patients had level I, 8 patients had level II and 5 had level III IVC involvement. The median operating time was 210 min (range 110–300) and median blood loss was 250 mls (range 100–550). No conversion to open surgey was required. The median length of hospital stay was 4 days (range 3–7), and only 3 patients developed Clavien Dindo Grade I complications (post-operative fever). All patients achieved negative surgical margins and histology was consistently clear cell carcinoma and Fuhrman Grade III-IV. Over a median follow-up period of 18 months, local recurrence occurred in 2 patients (11.8%). One patient had died of metastatic disease. Conclusion: Our technique of LRN with IVC thrombectomy is a safe and feasible alternative to open and robotic surgeries, with low complication rates and promising outcomes.

ObjectivesThis study establishes age- and sex-specific reference values for fat mass index (FMI), lean mass index (LMI), appendicular LMI (aLMI), and body fat distribution indices including Android/Gynoid % fat ratio and Trunk/Limb % fat ratio in multi-ethnic Singaporean adults.MethodsA population-based cross-sectional study using dual-energy X-ray absorptiometry (Hologic Discovery Wi) was carried out to measure whole body and regional fat and lean mass in community-dwelling adults. A total of 537 adults (57.5% women), aged from 21 to 90 years, were recruited from the large north-eastern residential town of Yishun. Age- and sex-specific percentile reference values were generated for FMI, LMI, aLMI, Android/Gynoid % fat ratio and Trunk/Limb % fat ratio using the Lambda-Mu-Sigma method. The relationship between the parameters and age were assessed through the Pearson's correlation coefficient.ResultsAll parameters demonstrated significant correlation with age (p < 0.05) for both men and women, except for LMI in women, with the strength of r ranging from 0.12 (weak correlation) to 0.54 (strong correlation). LMI (r = -0.45) and appendicular LMI (r = -0.54) were negatively associated with age in men while none (r = -0.06) to weak correlation (r = -0.14) were shown in women for the same parameters respectively. The Android/Gynoid % fat ratio and Trunk/Limb % fat ratio were positively related to age for both men (r = 0.37 & 0.43, p < 0.001) and women (r = 0.52 & 0.48, p < 0.001).ConclusionWe have established DXA-based body composition reference data for the Singapore adult population. These reference data will be particularly useful in geriatric, obesity and oncology clinics, enabling the prescription of appropriate therapy to individuals at risk of morbidity from unfavorable body composition phenotypes. It also adds on to the limited reference database on Southeast Asian body composition.