Ethics of Artificial Intelligence in Medicine and Ophthalmology.

BACKGROUND: This review explores the bioethical implementation of artificial intelligence (AI) in medicine and in ophthalmology. AI, which was first introduced in the 1950s, is defined as "the machine simulation of human mental reasoning, decision making, and behavior". The increased power of computing, expansion of storage capacity, and compilation of medical big data helped the AI implementation surge in medical practice and research. Ophthalmology is a leading medical specialty in applying AI in screening, diagnosis, and treatment. The first Food and Drug Administration approved autonomous diagnostic system served to diagnose and classify diabetic retinopathy. Other ophthalmic conditions such as age-related macular degeneration, glaucoma, retinopathy of prematurity, and congenital cataract, among others, implemented AI too. PURPOSE: To review the contemporary literature of the bioethical issues of AI in medicine and ophthalmology, classify ethical issues in medical AI, and suggest possible standardizations of ethical frameworks for AI implementation. METHODS: Keywords were searched on Google Scholar and PubMed between October 2019 and April 2020. The results were reviewed, cross-referenced, and summarized. A total of 284 references including articles, books, book chapters, and regulatory reports and statements were reviewed, and those that were relevant were cited in the paper. RESULTS: Most sources that studied the use of AI in medicine explored the ethical aspects. Bioethical challenges of AI implementation in medicine were categorized into 6 main categories. These include machine training ethics, machine accuracy ethics, patient-related ethics, physician-related ethics, shared ethics, and roles of regulators. CONCLUSIONS: There are multiple stakeholders in the ethical issues surrounding AI in medicine and ophthalmology. Attention to the various aspects of ethics related to AI is important especially with the expanding use of AI. Solutions of ethical problems are envisioned to be multifactorial.

Using cable ties to connect thoracostomy tubes to drainage devices decreases frequency of unplanned disconnection.

OBJECTIVES: Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection. METHODS: On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior ("BEFORE") and subsequent ("AFTER") to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days. RESULTS: 121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same. CONCLUSIONS: Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.

The Impact of Peyronie's Disease on the Patient: Gaps in Our Current Understanding.

Peyronie's disease results in a fibrous inelastic scar or hard plaque of the tunica albuginea of the penis that causes penile curvature deformity during erection that can be painful, distressing, and an impediment to sexual intercourse. In this article, the authors examine the knowledge gaps and research needs regarding the effect of Peyronie's disease on the patient's physical and psychological quality of life and on interpersonal relationships. On PubMed, the authors used the search terms Peyronie's disease, psychological, psychotherapy, male sexual dysfunction, partner, comorbid disease, satisfaction, and pain. Four categories describing the effect of Peyronie's disease were identified: (a) sexual dysfunction due to pain and altered penile shape, (b) psychological effects, (c) partner and relationship effects, and (d) effects of treatment options for Peyronie's disease. Results indicate that the examination of interventions aimed at education, coping, relationship distress, and sex therapy that may significantly improve patient quality of life is a core unmet need in Peyronie's disease. For many patients, the effect of Peyronie's disease is functional and psychological. Both aspects should be evaluated and treated in patients, which may require a referral. The physical pain, emotional distress and isolation, and partner and relationship discord that may be present require more attention.

Lower urinary tract symptoms improve with testosterone replacement therapy in men with late-onset hypogonadism: 5-year prospective, observational and longitudinal registry study.

PURPOSE: Many men with "late-onset hypogonadism" (LOH) experience lower urinary tract symptoms (LUTS) that can be distressing and may decrease quality of life. LUTS often appear in men when testosterone levels begin to decline, which could be a significant association. We investigated whether testosterone replacement could alleviate LUTS in men with LOH. METHODS: Two hundred and sixty-one hypogonadal patients (mean age 59.5 years) presenting with erectile dysfunction, having also been evaluated for LUTS, received a single testosterone undecanoate injection at day 1, at week 6 and quarterly thereafter. Parameters, including International Prostate Symptom Score (IPSS), post-voiding residual urine volume, transrectal ultrasound, prostate volume and prostate-specific antigen were measured at each treatment visit. Two hundred and fifty-nine patients were included in the full analysis set. These were subsequently divided into weight losers (L ≥ 5 % weight loss at last visit from baseline) and non-losers (NL). t test analyses were used to compare the IPSS means of these subgroups. The potentially confounding effect on IPSS of using the phosphodiesterase-5 inhibitor (PDE5i) vardenafil was also accounted for. RESULTS: Mean IPSS showed a significant decrease with time following initiation of testosterone treatment (p < 0.05). No significant differences were observed in either IPSS between L and NL groups or in mean IPSS between vardenafil users and non-users. CONCLUSION: Testosterone replacement is associated with improvements in LUTS which are not confounded by weight loss or PDE5i. The mechanisms of this association require further investigation.

Sex disparities in cancer mortality: the risks of being a man in the United States.

PURPOSE: In the United States more men are diagnosed with cancer than women. We quantified the differential mortality rates of nonsex specific cancers between the sexes and compared cancer stage distributions. MATERIALS AND METHODS: In this descriptive epidemiological study we obtained the incidence of new cancer cases, cancer deaths and stage distributions for the last 10 years in the United States from SEER (Surveillance, Epidemiology and End Results) program results. Sex specific cancers were excluded from study. We compared male-to-female relative mortality rate for all cancers as well as the average male-to-female relative mortality rate weighted by cancer incidence in the last 10 years. Sex specific stage distributions were also compared with the Kendall τ-c test. RESULTS: The male-to-female relative mortality rate for any cancer was 1.060 (95% CI 1.055-1.065). The average male-to-female relative mortality rate for the same cancer was 1.126 (95% CI 1.086-1.168). The discrepancy in incidence and mortality rates was stable for the last 10 years. Of the top 10 most common cancers men had an unfavorable stage distribution in all except colorectal, bladder and brain cancers. CONCLUSIONS: Men are more likely to have nonsex specific cancer than women and more likely to die of the cancer even after controlling for the incidence. This discrepancy has been stable for the last decade. For 7 of the 10 most commonly occurring nonsex specific cancers, representing 78% of all incident cancers, men are more likely to be diagnosed with advanced stage.

Review of current varicocelectomy techniques and their outcomes.

OBJECTIVES: • To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique • To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery. PATIENTS AND METHODS: • A PubMed English literature review of literature from 1995 to present. RESULTS: • Pregnancy rates were highest with microsurgical subinguinal technique • Varicocele recurrence rates were lowest with microsurgical subinguinal technique • Hydrocele formation rates were lowest with microsurgical inguinal technique • Surgical complications were highest in the laparoscopic technique • Varicocelectomy by itself or in conjunction with IVF is cost effective CONCLUSIONS: • Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes • Varicocelectomy is a cost effective treatment modality for infertility • Further research is needed to explore new developments in varicocelectomy.

Summary of the recommendations on sexual dysfunctions in men.

INTRODUCTION: Sexual health is an integral part of overall health. Sexual dysfunction can have a major impact on quality of life and psychosocial and emotional well-being. AIM: To provide evidence-based, expert-opinion consensus guidelines for clinical management of sexual dysfunction in men. METHODS: An international consultation collaborating with major urologic and sexual medicine societies convened in Paris, July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Committee members established scope and objectives for each chapter. Following an exhaustive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measures. New algorithms and guidelines for assessment and treatment of sexual dysfunctions were developed based on work of previous consultations and evidence from scientific literature published from 2003 to 2009. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of medical literature, and cultural and ethical considerations. RESULTS: Algorithms, recommendations, and guidelines for sexual dysfunction in men are presented. These guidelines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy, thus the International Consultation of Sexual Medicine (ICSM-5) developed a stepwise diagnostic and treatment algorithm for sexual dysfunction. The main goal of ICSM-5 is to unmask the underlying etiology and/or indicate appropriate treatment options according to men's and women's individual needs (patient-centered medicine) using the best available data from population-based research (evidence-based medicine). Specific evaluation, treatment guidelines, and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie's disease; and priapism. CONCLUSIONS: Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective.

Lack of awareness of erectile dysfunction in many men with risk factors for erectile dysfunction.

BACKGROUND: Men with erectile dysfunction often have concurrent medical conditions. Conversely, men with these conditions may also have underlying erectile dysfunction. The prevalence of unrecognized erectile dysfunction in men with comorbidities commonly associated with erectile dysfunction was determined in men invited to participate in a double-blind, randomized, placebo-controlled trial of sildenafil citrate. METHODS: Men ≥30 years old presenting with ≥1 erectile dysfunction risk factor (controlled hypertension, hypercholesterolemia, smoking, metabolic syndrome, stable coronary artery disease, diabetes, depression, lower urinary tract symptoms, obesity [body mass index ≥30 kg/m2] or waist circumference ≥40 inches), and not previously diagnosed with erectile dysfunction were evaluated. The screening question, "Do you have erectile dysfunction?," with responses of "no," "yes," and "unsure," and the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) were administered. RESULTS: Of 1084 men screened, 1053 answered the screening question and also had IIEF-EF scores. IIEF-EF scores indicating erectile dysfunction occurred in 71% (744/1053), of whom 54% (399/744) had moderate or severe erectile dysfunction. Of 139 answering "yes," 526 answering "unsure," and 388 answering "no," 96%, 90%, and 36%, respectively, had some degree of erectile dysfunction. The mean±SD (range) number of risk factors was 2.9 ± 1.7 (3-8) in the "yes" group, 3.2 ± 1.7 (3-9) in the "unsure" group, and 2.6 ± 1.5 (2-8) in the "no" group. CONCLUSION: Although awareness of having erectile dysfunction was low, most men with risk factors had IIEF-EF scores indicating erectile dysfunction. Erectile dysfunction should be suspected and assessed in men with risk factors, regardless of their apparent level of awareness of erectile dysfunction. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00343200.

A multicenter, double-blind, placebo-controlled trial to assess the efficacy of sildenafil citrate in men with unrecognized erectile dysfunction.

OBJECTIVE: Erectile dysfunction (ED) may be present but unrecognized in men with other comorbidities, such as cardiovascular disease (CVD), diabetes, or lower urinary tract symptoms (LUTS). The efficacy of sildenafil citrate treatment for ED in men who did not self-identify with or were unsure about whether they had ED, but had ED based on International Index of Erectile Function Erectile Function domain (IIEF-EF) scores, was evaluated. METHODS: Men with an ED-associated comorbidity were asked, "Do you have ED?" Those who answered "no" or "unsure" and were diagnosed with ED (score of or=30 kg/m(2)), and waist circumference >or=40 inches were the most frequently reported risk factors. Sildenafil-treated men had improved scores on both functional and psychosocial measures. Most adverse events were mild to moderate. CONCLUSIONS: Many men do not recognize that they have ED; sildenafil treatment improved sexual function and satisfaction in these men. Because ED affects quality of life, it should be suspected and assessed in men with risk factors for ED.

Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy.

OBJECTIVE: To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy. MATERIALS AND METHODS: From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope. RESULTS: All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs < 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes. CONCLUSION: Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.

Testosterone replacement therapy in hypogonadal men: assessing benefits, risks, and best practices.

Hypogonadism is a common condition, especially among older men, but often goes undiagnosed and untreated. It can be associated with a number of signs and symptoms that affect health and quality of life, including feelings of low energy and fatigue; decreased sex drive and performance; decreased muscle mass and strength; decreased bone mineral density; and increased body fat, particularly abdominal fat, a putative risk factor for metabolic syndrome and type 2 diabetes mellitus. The evidence supporting testosterone replacement therapy (TRT) in improving these and related conditions is strong and consistent for body composition and sexual function; moderately consistent for bone mineral density; inconsistent for insulin sensitivity, glycemic control, and lipid profiles; and weak and inconsistent for mood and cognitive function. The concern of some physicians about the potential for TRT to stimulate prostate cancer is not supported by decades of data accumulated to date, though studies of longer duration (eg, 10 years or more) would be even more convincing. Other research needs are discussed. As the front line of health care delivery, primary care physicians need to be vigilant in diagnosing and treating symptomatic hypogonadism. Based on current guidelines, we recommend assessing testosterone levels when an adult man exhibits signs of hypogonadism, and as part of normal medical screening in men starting at age 40 to 50 years, to establish a baseline. A physician should discuss the possibility of TRT with symptomatic patients who have a serum total testosterone level < 300 ng/dL. If TRT is initiated, a patient's response and adverse events should be assessed every 3 to 6 months, and therapy adjusted accordingly.

Long acting testosterone undecanoate therapy in men with hypogonadism: results of a pharmacokinetic clinical study.

PURPOSE: We determined the pharmacokinetics and safety of 750 mg long acting testosterone undecanoate given intramuscularly at 0, 4 and 14 weeks to men with hypogonadism. MATERIALS AND METHODS: A 24-week, single arm, open label, multicenter trial in 130 hypogonadal men 18 years or older who were screened for serum total testosterone less than 300 ng/dl was performed at 31 research sites in the United States between March and November 2007. Testosterone undecanoate (750 mg) was administered at baseline, and at weeks 4 and 14. Serum testosterone samples were collected on days 4, 7, 11, 14, 21, 28, 42, 56 and 70 following injection 3. Safety was assessed, eg biochemical markers and adverse events, secondary to testosterone undecanoate treatment. RESULTS: Of the 130 patients 116 with a mean +/- SE age of 54.2 +/- 0.90 years completed the 24-week trial. Following the week 14 injection mean +/- SD average serum testosterone was 494.9 +/- 141.46 ng/dl during the 70-day dosing interval and mean +/- SD maximum serum testosterone was 890.6 +/- 345.11 ng/dl with a mean concentration within the young healthy adult male range (300 to 1,000 ng/dl) in 94% of patients and a mean maximum concentration of below 1,500 ng/dl in 92%. Mean +/- SE hematocrit and hemoglobin increased from baseline to week 24 (43.3% +/- 0.32% to 45.7% +/- 0.35% and 14.6 +/- 0.11 to 15.5 +/- 0.13 gm/dl, respectively). Mean +/- SE prostate specific antigen increased from baseline to 24 weeks (1.0 +/- 0.08 to 1.3 +/- 0.10 ng/ml). No prostate cancer or gynecomastia was observed during this 24-week study. CONCLUSIONS: This 24-week clinical study demonstrated that 750 mg testosterone undecanoate depot injection administered intramuscularly at 0, 4 and 14 weeks achieves serum testosterone levels in the normal range during a 10-week dosing interval.

Robotic radical prostatectomy in patients with preexisting inflatable penile prosthesis (IPP).

PURPOSE: We present our initial experience with performing robotic-assisted prostatectomies in men with a 3-piece inflatable penile prosthesis with a pelvic reservoir. MATERIAL AND METHODS: Four patients underwent transperitoneal robotic-assisted radical prostatectomies with a penile prosthetic implant in place. The reservoir was left inflated for easy identification. A flaccid reservoir may be more difficult to identify, and be prone to damage. The reservoir was left attached to the abdominal wall. Dissection was performed outside the fibrous capsule of the reservoir. The tissue around the capsule of the reservoir peeled off without difficulty. Cutting current close to the capsule can be used if needed as per American Medical System with no limit to voltage. The penile prosthesis is then inflated to empty the reservoir creating more prevesical space and preventing the reservoir from obscuring visualization. The remaining portion of the procedure is completed using our standard technique. After completing the urethrovesical anastomosis using the 16 French Foley, the prosthesis is cycled under direct vision and the penile prosthesis is deflated (reservoir full). The prosthesis is not used for 6 weeks to prevent stretching of the urethrovesical anastomosis. RESULTS: All patients (n = 4) had no reported complications and all prostheses are functioning properly. The margin status was negative postoperatively. CONCLUSION: Robotic prostatectomy is technically feasible in patients with inflatable penile prostheses by surgeons experienced in robotic surgery. However, the presence of an indwelling penile prosthesis does increase the complexity of surgery.

Metabolic and cardiovascular effects of androgen deprivation therapy.

Prostate cancer is the most common gender-specific malignancy in men in the USA. Androgen-deprivation therapy (ADT) is commonly used in the treatment of metastatic or recurrent prostate cancer. The use of ADT is increasing with the advocacy of adjuvant and neoadjuvant ADT for treating asymptomatic patients with locally advanced prostate cancer. Although the use of ADT has resulted in improved survival in men with advanced prostate cancer, ADT, with its resulting severe hypogonadism, causes profound metabolic side-effects. We comprehensively reviewed previous reports using Medline searches of English-language literature (1950 to the present), with the keywords 'hypogonadism', 'testosterone', 'androgen deprivation therapy', 'hormonal treatment', 'prostate cancer', 'diabetes', 'metabolic syndrome', and 'cardiovascular disease'. Men with prostate cancer who undergo long-term ADT are at greater risk of developing dyslipidaemia, insulin resistance, hyperglycaemia and metabolic syndrome. These metabolic and physiological changes are a direct result of the induced severe hypogonadism and might predispose patients to a greater risk of cardiovascular morbidity and mortality. There is a need for prospective studies aimed and designed to investigate the metabolic and cardiovascular adverse effects of ADT, and assess the benefit/risk ratio, especially in special populations such as diabetics.

Effects of androgen deprivation on glycaemic control and on cardiovascular biochemical risk factors in men with advanced prostate cancer with diabetes.

INTRODUCTION AND OBJECTIVE: Androgen deprivation therapy of prostate cancer with luteinizing hormone releasing hormone agonists may result in loss of bone mass, changes in body composition and a deterioration of arterial stiffness. The present study monitored the effects of androgen deprivation therapy in men with insulin-dependent diabetes on glycaemic control and on biochemical cardiovascular risk markers. METHODS: Twenty-nine patients from a urology practice were included. All men had insulin-dependent diabetes mellitus prior to being diagnosed with metastatic prostate cancer. In a retrospective analysis, levels of fasting glucose, haemoglobin A1c, insulin requirements, total cholesterol, HDL, LDL, triglycerides, fibrinogen, PAI-1, tPA and C-reactive protein were obtained on at least eight occasions over a period of up to 24 months. RESULTS: Glycaemic control worsened substantially with increases of serum glucose requiring increases in insulin dosages. HbA1c levels rose indicating impaired glycaemic control. All biochemical cardiovascular risk markers deteriorated. CONCLUSION: In men with insulin-dependent diabetes, androgen deprivation therapy may have negative effects on their glycaemic control and may aggravate the biochemical risk profile of cardiovascular disease to which diabetics are predisposed. These observations are in agreement with the emerging role of low levels of testosterone in metabolic syndrome and insulin resistance.

The natural progression and remission of erectile dysfunction: results from the Massachusetts Male Aging Study.

PURPOSE: Erectile dysfunction affects more than 150 million men and is strongly associated with cardiovascular disease. A 1992 National Institutes of Health consensus development panel identified erectile dysfunction progression and spontaneous remission as priorities for investigation, but there are few data describing the natural course of the disorder following its initial presentation. This analysis estimates the frequency of erectile dysfunction progression and remission among aging men, and assesses the relation of progression/remission to demographics, socioeconomic factors, comorbidities and modifiable lifestyle characteristics. MATERIALS AND METHODS: Data from the Massachusetts Male Aging Study, a longitudinal study of men (401) 40 to 70 years old, were analyzed to assess erectile dysfunction severity following initial presentation of symptoms. Logistic regression was used to estimate the odds of erectile dysfunction progression/remission as a function of covariates. RESULTS: A total of 141 subjects (35%) exhibited erectile dysfunction remission (95% CI: 30%, 40%). Of 323 subjects with minimal or moderate baseline erectile dysfunction 107 (33%) exhibited erectile dysfunction progression (95% CI: 28%, 38%). The 78 subjects with complete erectile dysfunction were considered ineligible for progression and 45 (58%) of these exhibited complete erectile dysfunction at followup. Age and body mass index were associated with progression and remission, while smoking and self-assessed health status were associated with progression only. CONCLUSIONS: Natural remission and progression occur in a substantial number of men with erectile dysfunction. The association of body mass index with remission and progression, and the association of smoking and health status with progression, offer potential avenues for facilitating remission and delaying progression using nonpharmacological intervention. The benefits of such interventions for overall men's health may be far-reaching.

From proficiency to expert, when does the learning curve for robotic-assisted prostatectomies plateau? The Columbia University experience.

To describe our single-institution experience with our first 70 consecutive robotic-assisted laparoscopic prostatectomies (RLPs) with particular focus on effect of learning curve on operative time, length of stay and blood loss. We also report our short-term outcome data in this heterogeneous cohort of men with prostate cancer (PCa). We reviewed our institutional database for the first 70 consecutive RLPs performed by a single surgeon (DS) over a 21-month period (March 2003 to December 2004). Surgical, pathologic and postoperative outcomes were analyzed. In order to evaluate the impact of the surgeon's and institution's learning curve on outcomes, the cases were divided into quartiles and stratified accordingly to identify trends. Ninety-nine percent (69/70) of all procedures were successfully completed robotically. Mean blood loss, operative time and mean length of stay were 231 ml, 264 min and 1.9 days, respectively. At follow-up, 76% of all patients were fully continent (no pads) and 93% (62/67) had undetectable PSA. The most dramatic improvement in surgical outcomes was seen within the first quartile of cases; however a statistically significant improvement trend existed throughout the series. This included a downward trend in operative time (P < 0.00001), estimated blood loss (P < 0.00001), and length of hospital stay (P = 0.003). This trend continued when controlled for in a multivariate analysis. Our results compare favorably with other RLP series as well as conventional laparoscopic series. Proficiency is achieved within the first 20 cases; however surgical outcomes continue to improve for RLP throughout the first 70 cases and perhaps beyond.

Sexual function following bowel vaginoplasty.

PURPOSE: We review our 23-year experience with bowel vaginoplasty, with particular attention to postoperative quality of life and sexual function. MATERIALS AND METHODS: We reviewed the records of 57 patients who underwent bowel replacement vaginoplasty between 1980 and 2004. A total of 42 patients had the Mayer-Rokitansky syndrome, of whom 6 had varying forms of intersexuality, 6 had undergone surgery for pelvic malignancy, 1 had aphallia, 1 had cloacal exstrophy and 1 was the survivor of a conjoined twin separation. Replacement vaginoplasty was done using sigmoid colon in 39 patients, ileum in 9 and cecum in 9. Followup ranged from 18 months to 24 years, with a mean of 8.8 years. Outcome was evaluated by retrospective chart review, and the FSDQ, a validated, IRB approved instrument, was used to evaluate postoperative sexual function. RESULTS: Among the 57 patients postoperative sexual function was evaluated in 44, 9 were lost to followup and 4 were considered too young for evaluation. Of the 44 patients 36 responded to the FSDQ, 6 refused and 2 were unable to complete the questionnaire adequately. Of the 36 patients who responded 15 were married and 31 were sexually active. On a scale of 0 to 5, 28 patients (78%) reported sexual desire, 33% sexual arousal, 33% sexual confidence and 28 (78%) sexual satisfaction. In addition, 20 patients (56%) reported frequent orgasms, 8 (22%) occasional orgasms and 8 (22%) no orgasms. A total of 32 patients (89%) reported adequate lubrication for intercourse and 2 reported dyspareunia. Two of the 36 patients performed home dilation and required estrogen suppositories. A total of 34 patients used home douching and 20 required pads for mucus production. CONCLUSIONS: It appears that isolated bowel segments provided excellent tissue for vaginal replacement. For technical reasons we believe that colonic segments, particularly sigmoid, are preferable to small bowel. Sexual function following bowel vaginoplasty appears to be adequate and durable.

Application of angiogenic factors for therapy of erectile dysfunction: protein and DNA transfer of VEGF 165 into the rat penis.

OBJECTIVES: To establish a laboratory animal model for vascular endothelial growth factor (VEGF) transfer in the rat penis to invent a curative therapy for erectile dysfunction (ED). Vascular insufficiency is a common pathomechanism of ED. Previous investigations have shown neovascularization of ischemic organs after gene transfer of VEGF. METHODS: For VEGF-protein transfer, osmotic pumps were connected to the renal arteries of rats. The pumps were filled with human VEGF 165 protein (n = 20) or sterile saline (n = 20). After 28 days, a VEGF serum immunoassay was performed to document successful delivery. For VEGF-DNA transfer, liposome complexes containing VEGF 165 expression vectors were injected into rat corpora cavernosa. After immunostaining, computerized image analysis was performed to quantify the percentage of area (within the corpora cavernosa) covered by smooth muscle or endothelial cells. RESULTS: The immunoassay of the VEGF-protein transfer showed a 10-fold greater VEGF concentration in the serum of rats carrying VEGF pumps than in the control group. In the VEGF-DNA transfer, the penes transfected with VEGF 165 vectors showed a 283-bp polymerase chain reaction product according to specific primers for human VEGF. Although statistical trends were measured in the VEGF protein-treated group, no statistically significant difference in smooth muscle or endothelial cell content was found between the control and VEGF-treated rats. CONCLUSIONS: Our findings have established proof of principle for successful delivery of VEGF protein and VEGF-DNA transfer in the rat penis. This study was a prelude to attempt to manipulate genetically expression of angiogenic factors in insufficient erectile tissue as a curative therapy for ED.

Peyronie's disease: the epidemiology, aetiology and clinical evaluation of deformity.

There is a wide variety of topics covered in this section. The epidemiology, aetiology and clinical evaluation of the deformity in Peyronie's disease is described, followed by a discussion of recent advances in the biology of diabetes-associated bladder complications. Bladder cancer and its molecular prognostic factors are presented, and the section ends with an in-depth presentation of an evidence-based approach to the understanding of the pharmacological class effect in the management of prostatic diseases.