Does urethral length affect continence outcomes following robot assisted laparoscopic radical prostatectomy (RALP)?

BACKGROUND: Post-operative urinary incontinence is a significant concern for patients choosing to undergo a radical prostatectomy (RP) for treatment of prostate cancer. The aim of our study was to determine the effect of pre-operative MUL on 12 month continence outcomes in men having robot-assisted laparoscopic prostatectomy (RALP). METHODS: We use the South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC) database, to identify 602 patients who had undergone RALP by a high volume surgeon. Only patients who received an assessment and education by a specialist pelvic floor physiotherapist, had completed EPIC questionnaires before treatment and did not have radiotherapy treatment within 12 months of surgery were included. MUL measurements were taken from pre-operative magnetic resonance imaging (MRI) scans. The short-form version of the Expanded Prostate Cancer Index Composite (EPIC-26) was used to measure continence outcomes. Continence was defined as 100/100 in the EPIC-26 Urinary Continence domain score. RESULTS: The observed median MUL in this study was 14.6 mm. There was no association between MUL and baseline continence. MUL was associated with continence at 12 months post RALP (OR 1.13, 95% CI 1.03-1.21, p = 0.0098). In men who were continent before surgery, MUL was associated with return to continence at 12 months after RALP (OR 1.15, 1.05-1.28, p = 0.006). MUL was also associated with change in continence after surgery (ß = 1.22, p = 0.002). CONCLUSIONS: MUL had no effect on baseline continence but had a positive and significant association with continence outcomes over 12 months post RALP.

Candida albicans Colonizes and Disseminates to the Gastrointestinal Tract in the Presence of the Microbiota in a Severe Combined Immunodeficient Mouse Model.

Candida albicans is the leading cause of candidemia or other invasive candidiasis. Gastrointestinal colonization has been considered as the primary source of candidemia. However, few established mouse models that mimic this infection route are available. In the present study, we established a mouse model of disseminated candidiasis developed through the translocation of Candida from the gut. In this study, we developed a novel C. albicans GI colonization and dissemination animal model by using severe combined immunodeficient Rag2-/-IL2γc-/- (Rag2γc) mice, which lack functional T, B, NK cells, and IL2γc-dependent signaling. Rag2γc mice were highly susceptible to C. albicans gastrointestinal infection even in the presence of the gut microbiota. Within 4 weeks post infection, Rag2γc mice showed dose-dependent weight loss and disseminated candidiasis in more than 58% (7/12) of moribund mice. Histological analysis demonstrated abundant hyphae penetrating the mucosa, with significant neutrophilic infiltration in mice infected with wild-type C. albicans but not a filamentation-defective mutant. In moribund Rag2γc mice, the necrotic lesions and disrupted epithelial cells were associated with C. albicans hyphae. Notably, removal of the gut microbiota by antibiotics exacerbated the severity of fungal infection in Rag2γc mice, as demonstrated by elevated fungal burdens and accelerated weight loss and death. Furthermore, higher fungal burden and IL-1ß expression were prominently noted in the stomach of Rag2γc mice. In fact, a significant increase in circulating proinflammatory cytokines, including IL-6, TNF-α, and IL-10, indicative of a septic response, was evident in infected Rag2γc mice. Additionally, Rag2γc mice exhibited significantly lower levels of IL-22 but not IFN-γ or IL-17A than wild-type B6 mice, suggesting that IL-22 plays a role in C. albicans gastrointestinal infection. Collectively, our analysis of the Rag2γc mouse model revealed features of C. albicans gastrointestinal colonization and dissemination without the interference from antibiotics or chemotherapeutic agents, thus offering a new investigative tool for delineating the pathogenesis of C. albicans and its cross-talk with the gut microbiota.

Selective activation of inflammation factors by human parvovirus B19 and human bocavirus VP1 unique region on H9c2 cardiomyocyte.

Human parvovirus B19 (B19) and human bocavirus 1 (HBoV) are the only known pathogenic parvoviruses, and are responsible for a variety of diseases in human beings. Mounting evidence indicates a strong association between B19 infection and cardiac disorders including myocarditis, dilated cardiomyopathy and heart failure. However, very limited information about the role of HBoV in cardiac disorders is known. To elucidate the effects of B19 and HBoV on cardiac disorders, we expressed EGFP­conjugate constructs of B19­VP1 unique region (VP1u) and HBoV­VP1u, along with the mutants EGFP­B19­VP1uD175A and EGFP­HBoV­VP1uV12A, in H9c2 cells by stable transfection. The protein expression levels of EGFP, EGFP­B19­VP1u, EGFP­B19­VP1uD175A, EGFP­HBoV­VP1u and EGFP­HBoV­VP1uV12A in H9c2 cells were observed under a fluorescence microscope and confirmed by western blotting. Secreted phospholipase A2 (sPLA2) activity was detected in B19­VP1u and HBoV­VP1u but not B19­VP1uD175A and HBoV­VP1uV12A recombinant proteins. Significantly higher expression levels of MCP2 and IP­10 mRNA were detected in H9c2 cells that were transfected with pEGFP­B19­VP1u, compared with in those cells transfected with pEGFP­HBoV­VP1u, pEGFP­B19­VP1uD175A or pEGFP­HBoV­VP1uV12A. Significantly higher protein levels of IL­1ß and IL­6 were detected in H9c2 cells transfected with pEGFP­B19­VP1u or pEGFP­HBoV­VP1u, compared with in those cells transfected with pEGFP­B19­VP1uD175A or pEGFP­HBoV­VP1uV12A. Notably, significantly higher expression of both TNF­α and NF­κB was observed only in H9c2 cells transfected with pEGFP­B19­VP1u, but not in those cells transfected with pEGFP­HBoV­VP1u, pEGFP­B19­VP1uD175A or pEGFP­HBoV­VP1uV12A. These findings, to our knowledge for the first time, reveal the difference between B19­VP1u and HBoV­VP1u in H9c2 cells and provide insight into the roles of B19­VP1u and HBoV­VP1u in the pathogenesis of cardiac inflammation.

Impact of an acute surgical unit on patient outcomes in South Australia.

BACKGROUND: Compared with traditional (Trad) systems of managing emergency surgical presentations, the acute surgical unit (ASU) model provides an on-site registrar, on-call surgeon and dedicated emergency theatre, 24 h/day. To date, there have been no Australasian ASU studies of >3000 patients, nor from South Australia. METHODS: A retrospective historical control study compared the outcomes of adults admitted to the Lyell McEwin Hospital in the Trad (1 February 2010 to 31 July 2012) and ASU periods (1 August 2012 to 31 January 2015), who underwent an emergency general surgical procedure. RESULTS: A total of 4074 patients met inclusion criteria; 1688 and 2386 patients during the Trad and ASU periods, respectively. The cohorts were not significantly different in median age, gender or American Society of Anesthesiologists scores. Compared with the Trad period, improved median time from emergency department referral to theatre start (19.4 h versus 17.9 h, P < 0.0001) and median length of stay (2.32 days versus 2.06 days, P < 0.0001) were observed during the ASU period. The proportion of procedures performed in-hours was similar (77.9% versus 79.6%, P = 0.18). Secondary outcomes of rates of intensive care unit admission, emergency department representation within 30 days, in-hospital mortality and 1-year all-cause mortality were unchanged. CONCLUSION: Institution of an ASU was associated with decreased time from referral to theatre and reduced length of stay. The proportion of cases performed in-hours did not change. This may be related to the high Trad period rate and increased workload. These findings represent the largest Australasian study of an ASU and support the current model of care.

What are the demographic predictors in laparoscopic simulator performance?

BACKGROUND: Simulation is playing an increasingly important role in surgical education. There are a number of laparoscopic simulators of which the design and tasks vary considerably. It is unknown if any particular type may result in better outcomes for a specific population. This study assesses the predictors of acquisition of basic surgical skills on two different laparoscopic simulators. METHODS: Participants (n = 370) were randomized to be trained and assessed using either a fundamentals of laparoscopic surgery (FLS) or a LapSim (Surgical Science, Goteborg, Sweden) simulator. The number of attempts required to reach proficiency on individual tasks and on each simulator was recorded and compared with demographic data and surgical experience. RESULT: Skills acquisition on both simulators was positively affected by surgical experience. Gender was an influential factor on the LapSim with men reaching proficiency sooner than women. The effect of gaming had no clear influence on the participants' scores; however, for those who reported more than 1 h/week gaming, it had a positive influence on skills acquisition on the FLS and a negative influence on the LapSim. Playing a musical instrument had no impact. Practising non-surgical tasks requiring manual dexterity and handedness were not an influential factor in total proficient scores, but had a significant impact on individual task scores on the FLS simulator. CONCLUSIONS: The rate of skills acquisition on each simulator and individual tasks are influenced by different demographic characteristics of the participants. This has implications for surgical education as it may inform the selection of the most suitable laparoscopic simulators for specific populations of trainees.

A Literature Review and Case Report of Metastatic Pure Choriocarcinoma.

In 2012, testicular cancer was estimated to account for 940 disability adjusted life years in Australia; of these, 450 were years lost due to premature death and 500 were years of healthy life lost due to disease, disability, or injury (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 2012). Testicular choriocarcinoma is one of the rarest variants of testicular germ cell tumours, accounting for less than 1% of testicular germ cell tumours and only about 0.19% of all testicular tumours. Management involves radical orchidectomy and chemotherapy. Even then, prognosis is poor. This case report describes a 20-year-old male with pure testicular choriocarcinoma with pulmonary metastases which showed sustained and complete response to adjuvant chemotherapy consisting of bleomycin, etoposide, and cisplatin.

Colonic phytobezoar as a rare cause of large bowel obstruction.

Bezoars are masses formed by the concretion of stomach contents or debris within the gastrointestinal tract. Bezoars are rare and account for only 0.4-4% of all cases of gastrointestinal obstruction and mainly occur in the stomach or small intestine. Intestinal obstruction caused by colonic bezoars is extremely rare. We report a case of a distal sigmoid obstruction caused by a phytobezoar in a 60-year-old man with no obvious precipitating causes. He presented to the emergency department acutely unwell and a subsequent abdominal CT scan showed a mass within the proximal sigmoid colon suspicious for a bezoar. He proceeded to have an urgent laparotomy and the obstructive intraluminal mass in the sigmoid colon was identified and manually broken down. Subsequent histopathological assessment reported amorphous material and plant cellular matter consistent with the diagnosis of a phytobezoar.

A rare case of large cell neuroendocrine carcinoma.

We present a very rare case of de novo large cell neuroendocrine carcinoma (LCNEC) of the prostate in an 84-year-old man on a background of high grade, superficially invasive transitional cell carcinoma of the bladder. Pure LCNEC of the prostate is extremely rare. Most LCNEC of the prostate are thought to originate by clonal progression under the selection pressure of therapy and refractory to long-term hormonal treatment for adenocarcinoma of the prostate. De novo LCNEC is only described in case reports and is thought to develop via direct malignant transformation. Limited data in the English literature makes it difficult to accurately predict the prognosis of LCNEC of the prostate. However, current evidence suggesting that increasing neuroendocrine differentiation in prostate adenocarcinoma is associated with a higher stage, high-grade disease and a worse prognosis.

One lump or two? Concomitant Leydig cell tumour and paratesticular leiomyoma in an adult man.

We present the first reported case of a concomitant Leydig cell tumour (LCT) and paratesticular leiomyoma in an adult man with a history of bilateral cryptorchidism. An 80-year-old man presented with a 2-month history of a left testicular lump associated with mild discomfort and a gradual increase in size on a background of bilateral cryptorchidism requiring multiple orchidopexy procedures as a child. Ultrasound confirmed a lesion suspicious for malignancy and he proceeded to a left radical orchidectomy. Histopathological assessment of the left testis revealed a concomitant testicular LCT with rare malignant features and paratesticular leiomyoma.

Laparoscopic skills maintenance: a randomized trial of virtual reality and box trainer simulators.

OBJECTIVE: A number of simulators have been developed to teach surgical trainees the basic skills required to effectively perform laparoscopic surgery; however, consideration needs to be given to how well the skills taught by these simulators are maintained over time. This study compared the maintenance of laparoscopic skills learned using box trainer and virtual reality simulators. DESIGN: Participants were randomly allocated to be trained and assessed using either the Society of American Gastrointestinal Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) simulator or the Surgical Science virtual reality simulator. Once participants achieved a predetermined level of proficiency, they were assessed 1, 3, and 6 months later. At each assessment, participants were given 2 practice attempts and assessed on their third attempt. SETTING: The study was conducted through the Simulated Surgical Skills Program that was held at the Royal Australasian College of Surgeons, Adelaide, Australia. RESULTS: Overall, 26 participants (13 per group) completed the training and all follow-up assessments. There were no significant differences between simulation-trained cohorts for age, gender, training level, and the number of surgeries previously performed, observed, or assisted. Scores for the FLS-trained participants did not significantly change over the follow-up period. Scores for LapSim-trained participants significantly deteriorated at the first 2 follow-up points (1 and 3 months) (p < 0.050), but returned to be near initial levels by the final follow-up (6 months). CONCLUSIONS: This research showed that basic laparoscopic skills learned using the FLS simulator were maintained more consistently than those learned on the LapSim simulator. However, by the final follow-up, both simulator-trained cohorts had skill levels that were not significantly different to those at proficiency after the initial training period.