Turning up the HEAT: Surgical simulation of the Moses 2.0 laser in an anatomic model.

INTRODUCTION: With advancements in laser technology, urologists have been able to treat urinary calculi more efficiently by increasing the energy delivered to the stone. With increases in power used, there is an increase in temperatures generated during laser lithotripsy. The aim of this study was to evaluate the thermal dose and temperatures generated with four laser settings at a standardized power in a high-fidelity, anatomic model. METHODS: Using high-fidelity, 3D printed hydrogel models of a pelvicalyceal collecting system with a synthetic BegoStone implanted in the renal pelvis, surgical simulation of ureteroscopic laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations: at the stone and ureteropelvic junction. RESULTS: Greater cumulative thermal doses and maximal temperatures were achieved with greater ODCs and longer laser activation periods. There were statistically significant differences between the thermal doses and temperature profiles of the laser settings evaluated. Temperatures were greater closer to the tip of the laser fiber. CONCLUSIONS: Laser energy and frequency play an important role in the thermal loads delivered during laser lithotripsy. Urologists must perform laser lithotripsy cautiously when aggressively treating large renal pelvis stones, as dangerous temperatures can be reached. To reduce the risk of causing thermal tissue injury, urologists should consider reducing their ODC and laser-on time.

Getting hot in here! Comparison of Holmium vs. thulium laser in an anatomic hydrogel kidney model.

As laser technology has advanced, high-power lasers have become increasingly common. The Holmium: yttrium-aluminum-garnet (Ho:YAG) laser has long been accepted as the standard for laser lithotripsy. The thulium fiber laser (TFL) has recently been established as a viable option. The aim of this study is to evaluate thermal dose and temperature for the Ho:YAG laser to the TFL at four different laser settings while varying energy, frequency, operator duty cycle (ODC). Utilizing high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system (PCS) with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Ho:YAG laser or TFL. At a standard power (40W) and irrigation (17.9 ml/min), we evaluated four different laser settings with ODC variations with different time-on intervals. Temperature was measured at two separate locations. In general, the TFL yielded greater cumulative thermal doses than the Ho:YAG laser. Thermal dose and temperature were typically greater at the stone when compared away from the stone. Regarding the TFL, there was no general trend if fragmentation or dusting settings yielded greater thermal doses or temperatures. The TFL generated greater temperatures and thermal doses in general than the Ho:YAG laser with Moses technology. Temperatures and thermal doses were greater closer to the laser fiber tip. It is inconclusive as to whether fragmentation or dusting settings elicit greater thermal loads for the TFL. Energy, frequency, ODC, and laser-on time significantly impact thermal loads during ureteroscopic laser lithotripsy, independent of power.

WATTS happening? Evaluation of thermal dose during holmium laser lithotripsy in a high-fidelity anatomic model.

PURPOSE: To evaluate the thermal profiles of the holmium laser at different laser parameters at different locations in an in vitro anatomic pelvicalyceal collecting system (PCS) model. Laser lithotripsy is the cornerstone of treatment for urolithiasis. With the prevalence of high-powered lasers, stone ablation efficiency has become more pronounced. Patient safety remains paramount during surgery. It is well recognized that the heat generated from laser lithotripsy has the potential to cause thermal tissue damage. METHODS: Utilizing high-fidelity, 3D printed hydrogel models of a PCS with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations-at the stone and away from the stone. RESULTS: Temperatures were highest closest to the laser tip with a decrease away from the laser. Fluid temperatures increased with longer laser-on times and higher ODCs. Thermal doses were greater with increased ODCs and the threshold for thermal injury was reached for ODCs of 75% and 100%. CONCLUSION: Temperature generation and thermal dose delivered are greatest closer to the tip of the laser fiber and are not dependent on power alone. Significant temperature differences were noted between four laser settings at a standardized power (40 W). Temperatures can be influenced by a variety of factors, such as laser-on time, operator duty cycle, and location in the PCS.

Can preoperative planning using IRIS™ three-dimensional anatomical virtual models predict operative findings during robot-assisted partial nephrectomy?

Objective: To evaluate the predictive validity of IRIS™ (Intuitive Surgical®, Sunnyvale, CA, USA) as a planning tool for robot-assisted partial nephrectomy (RAPN) by assessing the degree of overlap with intraoperative execution. Methods: Thirty-one patients scheduled for RAPN by four experienced urologists were enrolled in a prospective study. Prior to surgery, urologists reviewed the IRIS™ three-dimensional model on an iphone Operating System (iOS) app and completed a questionnaire outlining their surgical plan including surgical approach, and ischemia technique as well as confidence in executing this plan. Postoperatively, questionnaires assessing the procedural approach, clinical utility, efficiency, and effectiveness of IRIS™ were completed. The degree of overlap between the preoperative and intraoperative questionnaires and between the planned approach and actual execution of the procedure was analyzed. Questionnaires were answered on a 5-point Likert scale and scores of 4 or greater were considered positive. Results: Mean age was 65.1 years with a mean tumor size of 27.7 mm (interquartile range 17.5-44.0 mm). Hilar tumors consisted of 32.3%; 48.4% of patients had R.E.N.A.L. nephrometry scores of 7-9. On preoperative questionnaires, the surgeons reported that in 67.7% cases they were confident that they can perform the procedure successfully, and on intraoperative questionnaires, the surgeons reported that in 96.8% cases IRIS™ helped achieve good spatial sensation of the anatomy. There was a high degree of overlap between preoperative and intraoperative questionnaires for the surgical approach, interpreting anatomical details and clinical utility. When comparing plans for selective or off-clamp, the preoperative plan was executed in 90.0% of cases intraoperatively. Conclusion: A high degree of overlap between the preoperative surgical approach and intraoperative RAPN execution was found using IRIS™. This is the first study to evaluate the predictive accuracy of IRIS™ during RAPN by comparing preoperative plan and intraoperative execution.

Robotic Assisted Transplant Nephrectomy: Case Series and Training Model for Improving Adoption.

Introduction: Open transplant nephrectomy for failed renal allograft is an invasive procedure associated with significant perioperative morbidity and mortality. Minimally invasive surgical approaches have improved a variety of patient outcomes for many surgeries. Thus, robotic assisted transplant nephrectomy (RATN) potentially offers significant patient benefit. Although previously reported, there remains a paucity of data on RATN outcomes and techniques. Methods: Four perfused, high-fidelity hydrogel models were created using previously described techniques and used for simulated RATN. Subsequently performed institutional cases were included for analysis. Intra- and postoperative variables along with patient demographics were retrospectively obtained through parsing of patient records. Results: Simulated nephrectomy time was 67.33 minutes (35.75 - 98.91). Five patients underwent RATN. There were four male and one female patients. The average age was 47 years. The most common indication was abdominal pain secondary to rejection (3/5). Mean blood loss was 188 mL; mean operative time was 243 minutes, and mean length of stay was 4.5 days. Intraoperatively there were two incidences of small cystotomies. One patient was readmitted within 30 days for intraabdominal abscess. Conclusion: This study adds to the growing literature around RATN, demonstrating the feasibility of the technique and reporting good outcomes for this cohort.

Assessment of body perception disturbances in complex regional pain syndrome: A systematic review using the COSMIN guideline.

OBJECTIVE: To conduct a systematic review to identify which tools are being used to assess body perception disturbances in Complex Regional Pain Syndrome (CRPS) and to provide an evidence-based recommendation in the selection of an assessment tool, based on measurement properties. DATABASES AND DATA TREATMENT: Five electronic databases (EMBASE, Pubmed, PsycInfo, Science Direct and Web of Science) were searched for English or French written articles, with no time restrictions. All original articles using a body perception assessment tool with adult patients with CRPS were selected, regardless of their design (controlled trials, single case, qualitative study). Two investigators screened abstracts, selected full articles and extracted data independently. RESULTS: Thirty-eight full-text papers were obtained and three main methods to evaluate body perception disturbances were identified: The Bath Body Perception Disturbance Scale, the Neglect-like Symptoms questionnaire adapted from Galer and the patient's body perception description. No full psychometric assessments were found. The Limb Laterality Recognition Task was also used in conjunction with another method. CONCLUSIONS: Three main assessment methods for CRPS body perception disturbances are currently used. Full psychometric evaluation has not been completed for any of the assessment methods. As a consequence, we could not fully apply the COSMIN guideline. To date, there is no agreement concerning the use of a specific questionnaire or scale. The results indicate a need for further research such as psychometric properties of these questionnaires. SIGNIFICANCE: This systematic review identified body perception disturbances assessment methods and their the psychometric properties in order to provide help and guidance to researchers and clinicians to investigate those clinical features.

A case report of a proximal corporal cavernosa injury presenting with butterfly perineal ecchymosis.

This is a case of a proximal corpus cavernosa fracture presenting with scrotal edema and butterfly perineal ecchymosis sparing the penile shaft. Preoperative MRI obviated the need for circumferential incision and degloving of the penis and guided immediate incision over the area of corporal injury. The presentation, diagnostic work-up, and surgical treatment are discussed.

Interplay between body schema, visuospatial perception and pain in patients with spinal cord injury.

BACKGROUND: Changes in body representations (body image and/or body schema) have been reported in several chronic musculoskeletal pain syndromes, but rarely in patients with neuropathic pain and never in patients with spinal cord injury (SCI)-related pain. METHODS: We used implicit motor imagery (the laterality judgement task and visuospatial body perception tests) in 56 patients with thoracic SCI with (n = 32) or without (n = 24) pain below the level of the injury, and in a group of matched healthy controls (n = 37). We compared the participants' reaction time and the accuracy with which they identified the laterality of hands and feet presented in various orientations. Visuospatial body perception was assessed with a series of tests referred to as the 'horizontal subjective body midline', and the umbilicus-reaching task (URT), in which participants were asked to estimate the location of the umbilicus under different experimental conditions. RESULTS: Both groups of patients had longer reaction times for the identification of laterality for the feet than for the hands, but with no difference in accuracy. This longer reaction time was not correlated with spinal lesion severity, but was directly related to both average pain intensity and specific neuropathic pain components. The URT was affected in both groups of patients, with no effect of pain intensity. By contrast, the horizontal subjective body midline task was unaffected. CONCLUSION: These results suggest an interplay between lower body scheme distortions and pain in patients with SCI. SIGNIFICANCE: Spinal cord injury is associated with alterations of lower body scheme as assessed with the laterality judgement task, which are directly related to pain intensity in patients with below-level neuropathic pain.

Central Nervous System Reorganization and Pain After Spinal Cord Injury: Possible Targets for Physical Therapy-A Systematic Review of Neuroimaging Studies.

BACKGROUND: Pain is one of the main symptoms associated with spinal cord injury (SCI) and can be associated with changes to the central nervous system (CNS). PURPOSE: This article provides an overview of the evidence relating to CNS changes (structural and functional) associated with pain in SCIs. DATA SOURCES: A systematic review was performed, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, on PubMed, Embase, and Web of Science in March 2018. STUDY SELECTION: Studies were selected if they concerned changes in the CNS of patients with SCI, regardless of the type of imagery. DATA EXTRACTION: Data were extracted by 2 blinded reviewers. DATA SYNTHESIS: There is moderate evidence for impaired electroencephalographic function and metabolic abnormalities in the anterior cingulate in patients experiencing pain. There is preliminary evidence that patients with pain have morphological and functional changes to the somatosensory cortex and alterations to thalamic metabolism. There are conflicting data regarding the relationships between lesion characteristics and pain. In contrast, patients without pain can display protective neuroplasticity. LIMITATIONS AND CONCLUSION: Further studies are required to elucidate fully the relationships between pain and neuroplasticity in patients with SCIs. However, current evidence might support the use of physical therapist treatments targeting CNS plasticity in patients with SCI pain.

Functional recovery after knee arthroplasty with regional analgesia: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Regional analgesia (RA) has been widely evaluated for pain relief after total knee arthroplasty (TKA). Its impact on functional recovery is less well known. OBJECTIVES: To evaluate the functional benefits of RA after TKA. DESIGN: Systematic review with a random-effects meta-analysis of randomised controlled trials comparing LRA with systemic analgesia on function in adults undergoing TKA for osteoarthritis. DATABASE SOURCES: MEDLINE, EMBASE, LILAC, Cochrane, CTRD databases. OUTCOMES: Length of stay (LOS) in hospital and early knee flexion range of motion (ROM), early and long-term knee function, serious adverse effects. RESULTS: Twenty-three studies (1246 patients) were included. LOS was significantly shorter for RA than for systemic analgesia (0.90 days, 95% confidence interval 0.3 to 1.4). Subgroup analyses found that only infiltration analgesia decreased the LOS. ROM during the first week was significantly higher for all techniques of RA than for systemic analgesia (9.23°, 95% confidence interval 4.6 to 13.9). No impact of regional analgesia techniques on global function in the longer term was demonstrated. No difference in serious adverse effects was found between RA and systemic analgesia. CONCLUSION: RA techniques compared with systemic analgesia have a beneficial impact on the LOS and the ROM achieved in the early postoperative period. Global function in the longer term after surgery seems unaffected by peri-operative RA. TRIAL REGISTRATION: CRD42014013995.

Expression of the Long Non-Coding RNA HOTAIR Correlates with Disease Progression in Bladder Cancer and Is Contained in Bladder Cancer Patient Urinary Exosomes.

Exosomes are 30-150nM membrane-bound secreted vesicles that are readily isolated from biological fluids such as urine (UEs). Exosomes contain proteins, micro RNA (miRNA), messenger RNA (mRNA), and long non-coding RNA (lncRNA) from their cells of origin. Although miRNA, protein and lncRNA have been isolated from serum as potential biomarkers for benign and malignant disease, it is unknown if lncRNAs in UEs from urothelial bladder cancer (UBC) patients can serve as biomarkers. lncRNAs are > 200 nucleotide long transcripts that do not encode protein and play critical roles in tumor biology. As the number of recognized tumor-associated lncRNAs continues to increase, there is a parallel need to include lncRNAs into biomarker discovery and therapeutic target algorithms. The lncRNA HOX transcript antisense RNA (HOTAIR) has been shown to facilitate tumor initiation and progression and is associated with poor prognosis in several cancers. The importance of HOTAIR in cancer biology has sparked interest in using HOTAIR as a biomarker and potential therapeutic target. Here we show HOTAIR and several tumor-associated lncRNAs are enriched in UEs from UBC patients with high-grade muscle-invasive disease (HGMI pT2-pT4). Knockdown of HOTAIR in UBC cell lines reduces in vitro migration and invasion. Importantly, loss of HOTAIR expression in UBC cell lines alters expression of epithelial-to-mesenchyme transition (EMT) genes including SNAI1, TWIST1, ZEB1, ZO1, MMP1 LAMB3, and LAMC2. Finally, we used RNA-sequencing to identify four additional lncRNAs enriched in UBC patient UEs. These data, suggest that UE-derived lncRNA may potentially serve as biomarkers and therapeutic targets.