Current use of testosterone therapy in LGBTQ populations.

Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.

Preoperative and intraoperative factors predictive of complications and stricture recurrence following multiple urethroplasty techniques.

Objectives: To investigate factors predictive of postoperative recurrence and complications in patients undergoing urethroplasty for stricture repair at a single center. Patients and methods: We retrospectively reviewed the records of 108 men who underwent urethroplasty for urethral stricture disease (USD) at a single center from 2016 to 2020. Demographic data, comorbidities, stricture history including etiology and prior treatments, patient-reported symptoms, and outcomes data were collected for analysis. Data were analyzed in aggregate, then, stratified by type of urethroplasty performed. Descriptive statistics, univariate analysis, multivariate logistic regression, and intergroup comparisons were completed using STATA, with an alpha value of 0.05 and a confidence interval of 95%. Results: The median age of our patients was 58 years (interquartile range: 42-69; range: 29-83), with a median stricture length of 2.0 cm (interquartile range: 1.0-4.5; range: 0.5-10). The most common stricture etiology was iatrogenic (n = 33, 31%) and the most common urethroplasty was anterior anastomotic urethroplasty (n = 38, 35%), followed by buccal mucosal graft (BMG) urethroplasty (n = 35, 32%). Twenty-four patients (22%) had stricture recurrence. Within the aggregate data, recurrence was significantly predicted by obesity (BMI > 30) (Odds Ratio [OR] 3.2, 95% Confidence Interval [CI]: 1.06-10), and the presence of postoperative complications (OR 6.3, CI: 1.9-21). The presence of any postoperative complications within 90 days was significantly predicted by stricture length ≥ 5 cm (OR 3.5, CI 1.09-12) and recurrence (OR 6.0, CI 1.7-21). Conclusion: Despite serving as the most definitive treatment for urethral stricture management, stricture recurrence and postoperative complications are not uncommon after urethroplasty. Obesity and stricture length negatively impact outcomes while a penile stricture location is associated with a lower recurrence rate, though this is not statistically significant.

Decipher correlation patterns post prostatectomy: initial experience from 2 342 prospective patients.

BACKGROUND: Currently, there are multiple commercially available RNA-based biomarkers that are Medicare approved and suggested for use by the National Comprehensive Cancer Network guidelines. There is uncertainty as to which patients benefit from genomic testing and for whom these tests should be ordered. Here, we examined the correlation patterns of Decipher assay to understand the relationship between the Decipher and patient tumor characteristics. METHODS: De-identified Decipher test results (including Decipher risk scores and clinicopathologic data) from 2 342 consecutive radical prostatectomy (RP) patients tested between January and September 2015 were analyzed. For clinical testing, tumor specimen from the highest Gleason grade was sampled using a 1.5 mm tissue punch. Decipher scores were calculated based on a previously locked model. Correlations between Decipher score and clinicopathologic variables were computed using Spearman's rank correlation. Mixed-effect linear models were used to study the association of practice type and Decipher score. The significance level was 0.05 for all tests. RESULTS: Decipher score had a positive correlation with pathologic Gleason score (PGS; r=0.37, 95% confidence interval (CI) 0.34-0.41), pathologic T-stage (r=0.31, 95% CI 0.28-0.35), CAPRA-S (r=0.32, 95% CI 0.28-0.37) and patient age (r=0.09, 95% CI 0.05-0.13). Decipher reclassified 52%, 76% and 40% of patients in CAPRA-S low-, intermediate- and high-risk groups, respectively. We detected a 28% incidence of high-risk disease through the Decipher score in pT2 patients and 7% low risk in pT3b/pT4, PGS 8-10 patients. There was no significant difference in the Decipher score between patients from community centers and those from academic centers (P=0.82). CONCLUSIONS: Although Decipher correlated with baseline tumor characteristics for over 2 000 patients, there was significant reclassification of tumor aggressiveness as compared to clinical parameters alone. Utilization of the Decipher genomic classifier can have major implications in assessment of postoperative risk that may impact physician-patient decision making and ultimately patient management.

Salvage robot assisted radical prostatectomy: A propensity matched study of perioperative, oncological and functional outcomes.

BACKGROUND: To report the perioperative, functional and oncological outcomes of salvage robot-assisted laparoscopic prostatectomy (s-RARP) in a propensity score-matched analysis. STUDY DESIGN: 53 patients underwent s-RARP at our institution. Perioperative, functional and oncological outcomes were compared between propensity matched cohorts. RESULTS: Patients in the s-RARP group were at significantly higher risk based on the D'Amico classification system (p = 0.010). Estimated blood loss, complication rate, hospital stay, BCR risk, persistent cancer and time to return of potency were similar between groups (full nerve spare [NS] n = 22). In the s-RARP cohort there was a higher prevalence of lymphovascular invasion (26.4% versus 13.2%; p = 0.032), time to catheter removal and a higher prevalence of anastomotic leaks in the postoperative period (34.0% vs 5.7%, p < 0.010). The hazard ratio for return to potency regardless of nerve sparing in the s-RARP group was 0.47 (95% CI 0.25-0.88). Significantly more patients undergoing primary RARP with partial nerve sparing (NS) recovered continence (p < 0.001) and potency (p = 0.043) compared to partial NS s-RARP patients. The return to continence and potency did not differ between full NS cases (n = 22; p = 0.616). CONCLUSIONS: Salvage RARP patients undergoing surgery have more high risk disease. Patients should be counseled that they are more likely to demonstrate anastomotic leakage on cystogram, and prolonged catheterization times. The time to potency and continence in s-RARP undergoing partial and no NS was significantly delayed (n = 49). The proportion of patients returning to potency and continence was also lower in our s-RARP group.

Robot-assisted radical prostatectomy: recent advances.

Robot assisted radical prostatectomy (RARP) represents the leading application of robotic surgery in the urologic field and it has become the main treatment option for localized prostate cancer (PCa) in the USA In the present review we summarized and critically analyzed the literature of the past five years about this widely used robotic procedure. RARP has continuously evolved in terms of technical modifications and procedural steps. Long-term data are now available, suggesting comparable oncological outcomes to those of open and laparoscopic radical prostatectomy. Good functional outcomes have also been demonstrated. Technological innovations and the introduction of more advanced robotic platforms featuring novel arm-integrated equipment, together with a mature clinical experience with the robotic approach, are likely to lead towards optimal outcomes. Despite the expanding clinical implementation of RARP in the management of prostate cancer, some issues related to this procedure remain matter of debate, such as costs, comparative outcomes versus other approaches, and its role in high risk disease.

Age stratified comparative analysis of perioperative, functional and oncologic outcomes in patients after robot assisted radical prostatectomy--A propensity score matched study.

INTRODUCTION AND OBJECTIVES: Our goal was to evaluate the perioperative, functional and intermediate term oncological outcomes of robot assisted radical prostatectomy (RARP) in patients ≥ 70 years. MATERIALS AND METHODS: The study population (N = 3241) consisted of consecutive patients who underwent RARP for localized prostate cancer by a single surgeon (VP) from January 2008 through February 2012. A query of our Institutional Review Board approved registry identified 400 men ≥ 70 years of age, with good functional status (Charlson co-morbidity index < 3). These patients were propensity score matched to younger patients. Perioperative and postoperative functional and oncologic outcomes for the two groups were compared. RESULTS: Full nerve sparing as well as the ease of nerve sparing were similar in 2 groups. Intra-operative complications were comparable. Postoperative complication occurrence rates were similar. At mean follow up of 34.1 months and 37.2 months respectively in younger and older patients, the continence rate was comparable in 2 groups (91.3% and 87.3%).Average time to continence and potency were similar in 2 groups. A greater proportion of younger patients became potent than elderly (52.3% vs 33.5%,p < 0.001).The biochemical recurrence (BCR) rate was comparable in 2 groups (7.8% vs 8.3%; p = 0.79). The mean time to BCR was also comparable in 2 groups (16 months vs 22.6 months; p = 0.07). CONCLUSIONS: In appropriately selected patients (minimal comorbidities with CCI ≤ 2, life expectancy >10 years, localized prostate cancer) RARP is a reasonable option in patients ≥ 7 0 years and provides comparable perioperative, functional and intermediate term oncologic outcomes as compared to younger patients.

The cerebellum in eye movement control: nystagmus, coordinate frames and disconjugacy.

In this review we discuss several aspects of eye movement control in which the cerebellum is thought to have a key role, but have been relatively ignored. We will focus on the mechanisms underlying certain forms of cerebellar nystagmus, as well as the contributions of the cerebellum to binocular alignment in healthy and diseased states. A contemporary review of our understanding provides a basis for directions of further inquiry to address some of the uncertainties regarding the contributions of the cerebellum to ocular motor control.

How pervasive are circadian oscillations?

Circadian oscillations play a critical role in coordinating the physiology, homeostasis, and behavior of biological systems. Once thought to only be controlled by a master clock, recent high-throughput experiments suggest many genes and metabolites in a cell are potentially capable of circadian oscillations. Each cell can reprogram itself and select a relatively small fraction of this broad repertoire for circadian oscillations, as a result of genetic, environmental, and even diet changes.

Simultaneous analysis and quantification of markers of manjisthadi churna using high performance thin layer chromatography.

Manjisthadi churna has been traditionally used in the Ayurvedic system of medicine and by traditional medical practices of India to treat hyperlipidemia. A rapid, simple and accurate method with high performance thin layer chromatography has been developed to standardised Manjisthadi churna using rubiadin, sennoside and ellagic acid as markers. Methanol extract of Manjisthadi churna were used for high performance thin layer chromatography on silica gel plates. The Rf of rubiadin, sennoside-A and ellagic acid were found to 0.48, 0.23 and 0.72, respectively with densitometric scanning at 280 nm and the calibration plot were linear in the range of 100-600 ng of markers. The correlation coefficients were higher than 0.99 were indicative of good linear dependence of peaks area on concentration. The rubiadin, sennoside-A and ellagic acid contents in Manjisthadi churna were found to be 0.014, 0.038 and 0.534% w/w, respectively. This method permits reliable quantification of rubiadin, sennoside-A and ellagic acid with good resolution and separation of the same from other constitutes of the extract of Manjisthadi churna. Recovery value from 95.66-102.33% showed the reliability and reproducibility of the method. The proposed high performance thin layer chromatography method for simultaneous quantification of markers in Manjisthadi churna can be used for routine quality testing.

Improvement in quality of life after arthroscopic capsular release for contracture of the shoulder.

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively. ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms.

The venous thromboembolic complications of shoulder and elbow surgery: a systematic review.

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria.

BACKGROUND: To analyze the trifecta outcome (continence, potency, and cancer control) in 300 cases of robotic-assisted laparoscopic radical prostatectomy (RARP). METHODS: A prospective assessment of outcomes in 300 consecutive patients that underwent a RARP performed by a single surgeon. Patients were grouped according to D'Amico risk criteria: Group I consisted of 'low-risk' cases (n = 64), Group II consisted of 'intermediate-risk' cases (n = 88), and Group III consisted of 'high-risk' cases (n = 148). Patients were evaluated for perioperative complications and the trifecta outcome. RESULTS: The operation time, blood loss, post-operative stay, duration of urethral catheterization, and perioperative complication rate were similar among all groups. The incidence of bilateral neurovascular bundle (NVB) preservation was significantly decreased with the increasing risk of cases (P < 0.001). The continence rates at the 1-week, 1-month, 3-month, 6-month, and 12-month follow-ups did not differ significantly between groups. The potency rates at the 12-month follow-up were not significantly different. The positive surgical margin and positive lymph node metastasis rate increased with the increasing risk of cases (P < 0.001). The biochemical recurrence rate (BCR, PSA >0.2 ng/mL) was 3.1, 11.36, and 19.59% in Groups I, II and III, respectively (P = 0.004). The trifecta outcome for RARP with bilateral NVB preservation showed no significant differences among groups. CONCLUSIONS: Undergoing a RARP is safe and feasible in high-risk prostate cancer patients. Compared to low-risk and intermediate-risk groups, the high-risk group had a significant higher incidence of positive surgical margin, positive lymph node metastasis, and BCR rate.

[Bidirectional barbed suture for bladder neck reconstruction, posterior reconstruction and vesicourethral anastomosis during robot assisted radical prostatectomy]. / Sutura barbada bidireccional para la reconstrucción del cuello vesical, la reconstrucción posterior y la anastomosis vesicouretral durante la prostatectomía radical asistida por robot.

BACKGROUND: The urethrovesical anastomosis is a particular challenging step of robot assisted radical prostatectomy (RARP). Failure to achieve a watertight anastomosis is associated with postoperative urinary leak and its consequences, which include paralytic ileus, prolonged catheterization, urinary peritonitis and possibly re-intervention. The bidirectional barbed suture is a new technology that may lead to improve the quality of the urethrovesical anastomosis. OBJECTIVE: To present our surgical technique of urethrovesical anastomosis, bladder neck reconstruction and posterior reconstruction, using a bidirectional barbed suture. MATERIAL AND METHODS: The bladder neck reconstruction, posterior reconstruction and vesicourethral anastomosis were performed using a 2-0 synthetic absorbable bidirectional monofilament barbed suture RESULTS: All cases were finished successfully without major complication or conversion to laparoscopic or open surgery. CONCLUSION: The authors successfully modified their RARP technique to take advantage of the properties of the bidirectional barbed suture. Comparative studies that evaluate objective outcomes such as leakage rates and operative time are needed to definitely establish the benefits of this device in comparison to the traditional absorbable monofilament.

[Robotic surgery: history and teaching impact]. / Cirugía robótica: Historia e impacto en la enseñanza.

CONTEXT: The purpose of this article is to review the history of robotic surgery, its impact on teaching as well as a description of historical and current robots used in the medical arena. SUMMARY OF EVIDENCE: Although the history of robots dates back to 2000 years or more, the last two decades have seen an outstanding revolution in medicine, due to all the changes that robotic surgery has made in the way of performing, teaching and practicing surgery. CONCLUSIONS: Robotic surgery has evolved into a complete and self-contained field, with enormous potential for future development. The results to date have shown that this technology is capable of providing good outcomes and quality care for patients.

[Robot-assisted laparoscopic prostatectomy: surgical technique]. / Prostatectomia laparoscopica robot assistita: tecnica chirurgica.

Prostate tumours are among the most frequently diagnosed solid tumours in males (a total of 192,280 new cases in the USA in 2009); since the approval of the PSA test by the Food and Drug Administration in 1986, incidence has risen significantly, particularly in the '90s; furthermore the spread of the PSA test has led to an increased frequency of cancer diagnosis at the localised stage. The standard treatment for tumour of the prostate is retropubic radical prostatectomy (RRP) which however is not morbidity-free, e.g. intraoperative bleeding, urinary incontinence and erectile dysfunction. This is why the interest of the scientific community has turned increasingly to mini-invasive surgical procedures able to achieve the same oncological results as the open procedure, but which also reduce the impact of the treatment on these patients' quality of life. The first step in this direction was laparoscopic prostatectomy described by Schuessler in 1992 and standardised by Gaston in 1997. However, the technical difficulty inherent in this procedure has limited its more widespread use. In May 2000 Binder and Kramer published a report on the first robot-assisted prostatectomy (RARP) using the Da Vinci system (da Vinci TM, Intuitive Surgical, Sunnyvale, CA, USA). From the original experience, RARP, which exploits the advantages of an enlarged, three-dimensional view and the ability of the instruments to move with 7 degrees of freedom, the technique has spread enormously all over the world. At the time of writing, in the USA, RARP is the most common therapeutic option for the treatment of prostate tumour at localised stage. In the present study we describe the RARP technique proposed by dr. Vipul Patel, head of the Global Robotic Institute (Orlando Fl).

Evolution of robot-assisted radical prostatectomy.

INTRODUCTION AND OBJECTIVE: Open radical prostatectomy (RRP) is the gold standard and most widespread treatment for clinically localized prostate cancer. However, in recent years robot-assisted laparoscopic prostatectomy (RARP) is rapidly gaining acceptance among urologists worldwide. We sought to outline our surgical technique of robotic radical prostatectomy and provide practical recommendations based on available reports and personal experience. We also critically review the current experience on RARP worldwide and compare the available data with the gold standard open RRP series. MATERIAL AND METHODS: A systematic review of the literature was performed for all published manuscripts between 1997 and 2008 using the keywords - 'robotic radical prostatectomy, 'robot-assisted radical prostatectomy', 'laparoscopic radical prostatectomy' and 'robotic' using the Medline database. RESULTS: A total of 226 original manuscripts on RARP were identified. Manuscripts were selected according to their relevance to the current topic (i.e. original articles, number of patients in the series, prospective data collection) and incorporated into this review. CONCLUSIONS: Eight years after the first RARP, multiple series are mature enough to demonstrate safety, efficiency and reproducibility of the procedure, as well as oncologic and functional outcomes comparable to its open counterpart. Further prospective, randomized studies comparing both surgical techniques are necessary in order to draw more definitive conclusions.

Robotic-assisted laparoscopic radical prostatectomy: initial 15 cases in Japan.

Recently, we have introduced robotic-assisted laparoscopic radical prostatectomy (RALP) in Japan. This article describes the details of a training program to shorten the learning curve in the absence of an urologist with expertise in robotic surgery. Five months after a 2-day training course of robotic surgery, RALP was first performed in Japan, and a total of 15 cases were performed in the subsequent 4 months. Our training program consisted of: (1) image training using surgical operation videos, (2) dry lab training using a sham pelvic cavity model, and (3) intraoperative mentoring. The operative procedure was divided into five consecutive stages, and time required to complete each stage was recorded. Robotic radical prostatectomy was completed in all patients without conversion to open surgery, except for the first patient in whom a restriction to a 2-h operation had been imposed by the ethics committee. The mean console time and the mean intraoperative blood loss (including urine) reduced from 264.2 min and 459.4 ml, respectively, in the first 11 cases, to 151 min and 133.3 ml, respectively, in the last three cases. With direct intraoperative guidance by the mentor during cases 13 and 14, the operation time was reduced at all five stages of the operative procedure. Our training program proved remarkably effective in reducing the learning curve of RALP in Japan, where there is no person with expertise in robotic surgery.

Robotic assisted laparoscopic radical prostatectomy: a review of the current state of affairs.

Open retropubic radical prostatectomy is the gold standard treatment for localised prostate cancer. However, the procedure has inherent morbidity associated to it. Therefore, less invasive surgical techniques have been sought, one such alternative is robotic-assisted laparoscopic radical prostatectomy. The advantages provided by robotic technology have the potential to minimise patient morbidity while improving both functional and oncological outcomes. Although it is a recent technological advancement, robotic surgery has shown an increasing rate of adoption worldwide. Currently more than 30,000 patients have undergone this procedure worldwide. We present a review of the available literature on robotic-assisted laparoscopic radical prostatectomy.