Distended Seminal Vesicles Are Involved in Specific Cerebral Sexual Arousal: A Pilot Study Using Functional Brain Imaging in Young Healthy Men.

Background: Whether seminal vesicles play a role in sexual activity in men is unknown. No study so far has compared the neural processing of visual sexual stimuli in men depending on the filling state of the seminal vesicles. Objective: To evaluate potential specific cortical activation by visual sexual stimuli with distended and empty seminal vesicles. Design setting and participants: A prospective case-control trial was conducted. Six male individuals underwent two visits on 2 consecutive days for hormone analyses; Derogatis Interview for Sexual Functioning (DISF) questionnaire; functional magnetic resonance imaging (fMRI) with passively viewing sexual, neutral, positive, and negative emotional pictures; and structural pelvic MRI. After the first visit, the participants had to empty seminal vesicles by masturbation. During fMRI, every participant viewed alternating blocks of sexual, neutral, positive, and negative emotional pictures. Outcome measurements and statistical analysis: Comparisons between days 1 and 2 were evaluated using paired t tests. Results and limitations: No significant differences were observed regarding hormone analyses, DISF questionnaire score, and arousal scoring between days 1 and 2. Seminal vesicle volume was significantly lower on day 2 (p = 0.003). Significantly higher activation was observed in the right precentral gyrus, middle frontal gyrus, and right superior temporal sulcus when contrasted for sexual over neutral (p < 0.05). Conclusions: In response to pictures with sexual emotional content, significantly higher activation was detected in brain areas involved in motor preparation (arousal) and coding of desirability of visual sexual stimuli in men with distended seminal vesicles than in the same men with emptied seminal vesicles. This suggests that the filling state of the seminal vesicles may influence sexual desire in men. Patient summary: We compared brain activity of men with filled and emptied seminal vesicles by functional magnetic resonance imaging. We found that men with filled seminal vesicles had higher activation of brain areas involved in arousal and sexual desire.

Residual Stresses Measurements in Laser Powder Bed Fusion Using Barkhausen Noise Analysis.

In recent years, the advancement of technology brought the laser powder bed fusion process to its industrialisation step. Despite all the advancements in process repeatability and general quality control, many challenges remain unsolved due to the intrinsic difficulties of the process, notably the residual stresses issue. This work aimed to assess the usability of Barkhausen noise analysis (BNA) for the residual stress in situ monitoring of laser powder bed fusion on Maraging steel 300 (18Ni-300/1.2709). After measuring the evolution of grain size distribution over process parameter changes, two series of experiments were designed. First, a setup with an external force allows to validate the working principle of BNA on the chosen material processed using LPBF. The second experiment uses on-plates samples with different residual stress states. The results show a good stability in microstructure, a prerequisite for BNA. In addition, the external load setup acknowledges that signal variation correlates with the induced stress state. Finally, the on-plate measurement shows a similar signal variation to what has been observed in the literature for residual stress variation. It is shown that BNA is a suitable method for qualitative residual stresses variation monitoring developed during the LPBF process and underlines that BNA is a promising candidate as an in situ measurement method.

Development of a model to predict the probability of incurring a complication during spine surgery.

PURPOSE: Predictive models in spine surgery are of use in shared decision-making. This study sought to develop multivariable models to predict the probability of general and surgical perioperative complications of spinal surgery for lumbar degenerative diseases. METHODS: Data came from EUROSPINE's Spine Tango Registry (1.2012-12.2017). Separate prediction models were built for surgical and general complications. Potential predictors included age, gender, previous spine surgery, additional pathology, BMI, smoking status, morbidity, prophylaxis, technology used, and the modified Mirza invasiveness index score. Complete case multiple logistic regression was used. Discrimination was assessed using area under the receiver operating characteristic curve (AUC) with 95% confidence intervals (CI). Plots were used to assess the calibration of the models. RESULTS: Overall, 23'714/68'111 patients (54.6%) were available for complete case analysis: 763 (3.2%) had a general complication, with ASA score being strongly predictive (ASA-2 OR 1.6, 95% CI 1.20-2.12; ASA-3 OR 2.98, 95% CI 2.19-4.07; ASA-4 OR 5.62, 95% CI 3.04-10.41), while 2534 (10.7%) had a surgical complication, with previous surgery at the same level being an important predictor (OR 1.9, 95%CI 1.71-2.12). Respectively, model AUCs were 0.74 (95% CI, 0.72-0.76) and 0.64 (95% CI, 0.62-0.65), and calibration was good up to predicted probabilities of 0.30 and 0.25, respectively. CONCLUSION: We developed two models to predict complications associated with spinal surgery. Surgical complications were predicted with less discriminative ability than general complications. Reoperation at the same level was strongly predictive of surgical complications and a higher ASA score, of general complications. A web-based prediction tool was developed at https://sst.webauthor.com/go/fx/run.cfm?fx=SSTCalculator .

Intensified and Standardized Digital Communication with Cystectomy Patients as a Potentially Simple and Effective Modality for Early Detection of Postoperative Complications: Results from a Pilot Study.

BACKGROUND: Postoperative readmission rates following radical cystectomy remain significant. Early identification of emerging complications could potentially allow for immediate institution of therapy. OBJECTIVE: To intensify postoperative patient-physician communication via a cellphone-based health care application (CHA) and to evaluate its potential for early detection of complications. DESIGN SETTING AND PARTICIPANTS: This was a pilot study involving 18 radical cystectomy patients. During the first 30 d, patients received a push cellphone notification twice a week requesting data input into the CHA. This was reduced to once a week from day 31 to day 90. De-identified recorded data were reviewed by the surgeon involved. If deemed necessary, patients were contacted by the surgeon via telephone to obtain more detailed clinical information. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics were used. RESULTS AND LIMITATIONS: Of the 18 patients enrolled, all completed the 90-d reporting period. On two occasions, interventions were necessary on the basis of data recorded on the CHA. One neobladder patient was given antibiotic therapy for pyelonephritis. Another patient reported weight loss and nausea with clinical suspicion of metabolic acidosis, and his sodium bicarbonate and fluid intake were increased. Limitations include the small number of cases from a single low-volume center. CONCLUSIONS: CHA-based monitoring of clinical parameters within the crucial 90-d postoperative period following radical cystectomy provides meaningful information. In this pilot study, two potential readmissions were possibly avoided on the basis of recorded basic vital signs and early intervention. PATIENT SUMMARY: Besides regular clinic follow-up visits after radical cystectomy, additional aids such as a cellphone-based health care application can provide treating physicians with relevant clinical information and may help to identify imminent deviations from normal postoperative recovery at an early stage.

Influence of previous surgery on patient-rated outcome after surgery for degenerative disorders of the lumbar spine.

PURPOSE: Few studies have used multivariate models to quantify the effect of multiple previous spine surgeries on patient-oriented outcome after spine surgery. This study sought to quantify the effect of prior spine surgery on 12-month postoperative outcomes in patients undergoing surgery for different degenerative disorders of the lumbar spine. METHODS: The study included 4940 patients with lumbar degenerative disease documented in the Spine Tango Registry of EUROSPINE, the Spine Society of Europe, from 2004 to 2015. Preoperatively and 12 months postoperatively, patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10 scale). Patients' medical history and surgical details were recorded using the Spine Tango Surgery 2006 and 2011 forms. Multiple linear regression models were used to investigate the relationship between the number of previous surgeries and the 12-month postoperative COMI score, controlling for the baseline COMI score and other potential confounders. RESULTS: In the adjusted model including all cases, the 12-month COMI score showed a 0.37-point worse value [95 % confidence intervals (95 % CI) 0.29-0.45; p < 0.001] for each additional prior spine surgery. In the subgroup of patients with lumbar disc herniation, the corresponding effect was 0.52 points (95 % CI 0.27-0.77; p < 0.001) and in lumbar degenerative spondylolisthesis, 0.40 points (95 % CI 0.17-0.64; p = 0.001). CONCLUSIONS: We were able to demonstrate a clear "dose-response" effect for previous surgery: the greater the number of prior spine surgeries, the systematically worse the outcome at 12 months' follow-up. The results of this study can be used when considering or consenting a patient for further surgery, to better inform the patient of the likely outcome and to set realistic expectations.

Radical cystectomy with super-extended lymphadenectomy: impact of separate vs en bloc lymph node submission on analysis and outcomes.

OBJECTIVE: To update our previous analysis of the clinical and pathological impact of the change in the submission of lymphadenectomy specimens from en bloc to 13 separate anatomically defined packets, which took place at the University of Southern California in May 2002, and to determine whether lymph node (LN) packeting resulted in any change in oncological outcomes. PATIENTS AND METHODS: A total of 846 patients who underwent radical cystectomy (RC) with super-extended LN dissection for cTxN0M0 bladder cancer between January 1996 and December 2007 were identified. Specimens of 376 patients were sent en bloc (group 1), and specimens of 470 patients were sent in 13 separate anatomical packets (group 2). RESULTS: The pathological tumour stage distribution and the proportion of LN-positive patients (group 1: 82 patients [22%] versus group 2: 99 patients [21%]; P = 0.80) were similar between the two groups: the median [range] number of total LNs identified increased significantly (group 1: 32 [10-97] versus group 2: 65 [10-179]; P < 0.001). LN density decreased (group 1, 11% versus group 2, 4%; P = 0.005). The median [range] number of positive LNs removed was similar (group 1: 0 [0-30] versus group 2: 0 [0-97]; P = 0.87). No nodal stage shift was observed. The 5-year overall survival (group 1: 58% versus group 2: 59%; P = 0.65) and recurrence-free survival rates (group 1: 68% versus group 2: 70%; P = 0.57) were similar. CONCLUSIONS: The incidence of patients with positive LNs remained unchanged, regardless of how the LN specimen was submitted. Submitting 13 separate nodal packets significantly increased the total LN yield, but did not result in a significant increase in the number of positive LNs or a consecutive nodal stage shift and did not affect oncological outcomes. Based on these results LN density is not an accurate prognosticator.

Outcome in patients with exclusive carcinoma in situ (CIS) after radical cystectomy.

OBJECTIVE: To evaluate oncological outcomes of patients with carcinoma in situ (CIS) exclusively at radical cystectomy (RC) and no previous history of ≥T1 disease. PATIENTS AND METHODS: Patients undergoing RC with curative intent for CIS between 1971 and 2008 at the University of Southern California were included if they met all the following criteria: (i) pathological CIS-only disease at RC, (ii) preoperative clinical stage cCIS and/or cCIS + cTa, and (iii) no previous history of lamina propria invasion (≥pT1). Kaplan-Meier plots were used to estimate the probabilities of recurrence-free survival (RFS) and overall survival (OS). RESULTS: Of the 1964 consented patients 52 met the inclusion criteria with a median (range) follow-up of 8.5 (0.008-34) years. A median (range) of 36 (10-95) lymph nodes were identified per patient but no metastases found. Estimated 5- and 10-year RFS rates were 94% and 90%, respectively and estimated 5- and 10-year OS rates were 85% and 66%, respectively. Different mechanisms of recurrence were found in four (8%) patients after a median (range) interval of 2.4 (0.6-7.1) years. While two patients had metachronous recurrence within the urinary tract, the first of the other two had early systemic recurrence and the second late local recurrence. CONCLUSIONS: We noticed excellent outcomes after RC for CIS-only disease. However, patients may have synchronous and/or develop metachronous tumours, as well as local and/or distant/systemic recurrence that can be cured but may also lead to fatal outcomes.

Outcomes of radical cystectomy with extended lymphadenectomy alone in patients with lymph node-positive bladder cancer who are unfit for or who decline adjuvant chemotherapy.

OBJECTIVE: To analyse the long-term outcomes of patients with lymph node (LN)-positive bladder cancer, who did not receive any adjuvant therapy after radical cystectomy (RC) and extended pelvic lymph node dissection (ePLND). PATIENTS AND METHODS: We conducted a retrospective, combined cohort analysis based on two prospectively maintained cystectomy databases from the University of Southern California and the University of Bern. Eligible patients underwent RC with ePLND for cN0M0 disease but were found to have LN-positive disease. No patient had neoadjuvant therapy, and all had negative surgical margins. Kaplan-Meier plots were used to estimate recurrence-free survival (RFS) and overall survival (OS). Subgroup comparisons were performed using log-rank tests, and multivariable analysis was based on Cox proportional hazard models. RESULTS: Of 521 patients with LN-positive disease, 251 (48%) never received adjuvant therapy. Although the pathological stage distribution was similar, the 251 patients who did not receive adjuvant therapy were older and had both fewer total and positive LNs than those who underwent adjuvant therapy. The median RFS for patients treated with RC alone was 1.6 years. Recurrences mainly occurred <2 years after RC, resulting in 5- and 10-year RFS rates of 32 and 26%, respectively. Pathological T stage, the total number of LNs and the number of positive LNs detected were independent predictors of RFS and OS. CONCLUSIONS: In this study, 25% of patients with documented LN metastases who did not receive adjuvant therapy were cured with RC and ePLND; however, a few relapses may occur later than 3 years. Predictors of survival were pathological T stage, the number of total LNs and the number of positive LNs identified.

Timing and outcomes for radical cystectomy in nonmuscle invasive bladder cancer.

PURPOSE OF REVIEW: To provide an overview on the available clinical and pathological factors in high-risk nonmuscle invasive bladder cancer (NMIBC) patients that help to approximate the risk of progression to muscle invasion and identify 'the' patients requiring timely cystectomy. The value of a high-quality transurethral tumor resection is pointed out. Outcomes following radical cystectomy are compared with a primarily bladder preserving strategy. RECENT FINDINGS: Carcinoma in situ within the prostatic urethra of NMIBC patients impacts on patient's outcome. Therefore, biopsies taken from the prostatic urethra improve the initial tumor staging accuracy. Lamina propria substaging may provide more detailed prognostic information. Lympho-vascular invasion within the transurethral resection specimen may help to detect patients who benefit from timely cystectomy. Recent findings from patients undergoing radical cystectomy including super-extended lymphadenectomy for clinically NMIBC confirm the substantial rate (25%) of tumor understaging. The fact that almost 10% were found to harbor lymph node metastases underlines the necessity to perform a meticulous lymphadenectomy in NMIBC patients undergoing radical cystectomy. SUMMARY: High-quality transurethral bladder tumor resection including underlying muscle fibers is of utmost importance. Nevertheless, tumor understaging remains an issue of concern and warrants the value of a second transurethral resection in high-risk NMIBC patients. There is a persisting lack of rigid therapeutic recommendations in patients with high-risk NMIBC. Instead, treatment strategy is based on individual risk factors. However, irrespective of initial treatment strategy, there is a subgroup of high-risk NMIBC patients with progressive disease, leading almost inevitably to death.

Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades.

OBJECTIVE: To evaluate oncological outcome trends over the last three decades in patients after radical cystectomy (RC) and extended pelvic lymph node (LN) dissection. PATIENTS AND METHODS: Retrospective analysis of the University of Southern California (USC) RC cohort of patients (1488 patients) operated with intent to cure from 1980 to 2005 for biopsy confirmed muscle-invasive urothelial bladder cancer. To focus on outcomes of unexpected (cN0M0) LN-positive patients, the USC subset was extended with unexpected LN-positive patients from the University of Berne (UB) (combined subgroup 521 patients). Patients were grouped and compared according to decade of surgery (1980-1989/1990-1999/≥2000). Survival probabilities were calculated with Kaplan-Meier plots, log-rank tests compared outcomes according to decade of surgery, followed by multivariable verification. RESULTS: The 10-year recurrence-free survival was 78-80% in patients with organ-confined, LN-negative disease, 53-60% in patients with extravesical, yet LN-negative disease and ≈30% in LN-positive patients. Although the number of patients receiving systemic chemotherapy increased, no survival improvement was noted in either the entire USC cohort, or in the combined LN-positive USC-UB cohort. In contrast, patient age at surgery increased progressively, suggesting a relative survival benefit. CONCLUSIONS: Radical surgery remains the mainstay of therapy for muscle-invasive bladder cancer. Yet, our study reveals predictable outcomes but no survival improvement in patients undergoing RC over the last three decades. Any future survival improvements are likely to result from more effective systemic treatments and/or earlier detection of the disease.

Novel prototype sewing device, EndoSew®, for minimally invasive surgery: an extracorporeal ileal conduit construction pilot study in 10 patients.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The EndoSew(®) prototype was first tested in a porcine model several years ago. The investigators found it both simple to master and reliable, its greatest advantage being a 2.4-fold time saving compared with straight laparoscopic suturing. In addition to that publication, there is a single case report describing the performance of an open EndoSew(®) suture to close parts (16 cm) of an ileal neobladder. The time for suturing the 16 cm ileum was 25 min, which is in line with our experience. The knowledge on this subject is limited to these two publications. We report on the first consecutive series of ileal conduits performed in humans using the novel prototype sewing device EndoSew(®). The study shows that the beginning and the end of the suture process represent the critical procedural steps. It also shows that, overall, the prototype sewing machine has the potential to facilitate the intracorporeal suturing required in reconstructive urology for construction of urinary diversions. OBJECTIVE: To evaluate the feasibility and safety of the novel prototype sewing device EndoSew(®) in placing an extracorporeal resorbable running suture for ileal conduits. PATIENTS AND METHODS: We conducted a prospective single-centre pilot study of 10 consecutive patients undergoing ileal conduit, in whom the proximal end of the ileal conduit was closed extracorporeally using an EndoSew(®) running suture. The primary endpoint was the safety of the device and the feasibility of the sewing procedure which was defined as a complete watertight running suture line accomplished by EndoSew(®) only. Watertightness was assessed using methylene blue intraoperatively and by loopography on postoperative days 7 and 14. Secondary endpoints were the time requirements and complications ≤30 days after surgery. RESULTS: A complete EndoSew(®) running suture was feasible in nine patients; the suture had to be abandoned in one patient because of mechanical failure. In three patients, two additional single freehand stitches were needed to anchor the thread and to seal tiny leaks. Consequently, all suture lines in 6/10 patients were watertight with EndoSew(®) suturing alone and in 10/10 patients after additional freehand stitches. The median (range) sewing time was 5.5 (3-10) min and the median (range) suture length was 4.5 (2-5.5) cm. There were no suture-related complications. CONCLUSIONS: The EndoSew(®) procedure is both feasible and safe. After additional freehand stitches in four patients all sutures were watertight. With further technical refinements, EndoSew(®) has the potential to facilitate the intracorporeal construction of urinary diversions.

Pelvic lymph node dissection in the context of radical cystectomy: a thorough insight into the connection between patient, surgeon, pathologist and treating institution.

Pelvic lymph node dissection (PLND) in patients with bladder cancer varies widely in extent, technique employed, and pathological workup of specimens. The present paper provides an overview of the existing evidence regarding the effectiveness of PLND and elucidates the interactions between patient, surgeon, pathologist, and treating institution as well as their cumulative impact on the final postoperative lymph node (LN) staging. Bladder cancer patients undergoing radical cystectomy with extended PLND appear to have better oncologic outcomes compared to patients undergoing radical cystectomy and limited PLND. Attempts have been made to define and assess the quality of PLND according to the number of lymph nodes identified. However, lymph node counts depend on multiple factors such as patient characteristics, surgical template, pathological workup, and institutional policies; hence, meticulous PLND within a defined and uniformly applied extended template appears to be a better assurance of quality than absolute lymph node counts. Nevertheless, the prognosis of the patients can be partially predicted with findings from the histopathological evaluation of the PLND specimen, such as the number of positive lymph nodes, extracapsular extension, and size of the largest LN metastases. Therefore, particular prognostic parameters should be addressed within the pathological report to guide the urologist in terms of patient counseling.

Parenteral nutrition does not improve postoperative recovery from radical cystectomy: results of a prospective randomised trial.

BACKGROUND: After radical cystectomy, patients are in a catabolic state because of postoperative stress response, extensive wound healing, and ileus. OBJECTIVE: To evaluate whether recovery can be improved with total parenteral nutrition (TPN) in patients following extended pelvic lymph node dissection (ePLND), cystectomy, and urinary diversion (UD). DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective, randomised, single-centre study of 157 consecutive cystectomy patients. INTERVENTION: Seventy-four patients (group A) received TPN during the first 5 postoperative days, with additional oral intake ad libitum. Eighty-three patients (group B) received oral nutrition alone. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the occurrence of postoperative complications. Secondary outcomes were time to recovery of bowel function, biochemical nutritional (serum albumin, serum prealbumin, serum total protein) and inflammatory (C-reactive protein) parameters, length of hospital stay, and costs attributed to the TPN. The Pearson χ(2) test was used for dichotomous variables; the Wilcoxon rank sum test was used for continuous variables. RESULTS AND LIMITATIONS: Postoperative complications occurred in 51 patients (69%) in group A and in 41 patients (49%) in group B (p=0.013), a difference resulting from group A having more infectious complications than group B (32% vs 11%; p=0.001). Serum prealbumin and serum total protein were significantly lower in group B on postoperative day 7 but not on postoperative day 12. Time to gastrointestinal recovery and length of hospital stay did not differ between the two groups. The costs for TPN were €614 per patient. A potential limitation is the use of a glucose-based parenteral nutrition without lipids. CONCLUSIONS: Postoperative TPN is associated with a higher incidence of complications, mainly infections, and higher costs following ePLND, cystectomy, and UD versus oral nutrition alone.

Peri-interventional antibiotic prophylaxis only vs continuous low-dose antibiotic treatment in patients with JJ stents: a prospective randomised trial analysing the effect on urinary tract infections and stent-related symptoms.

OBJECTIVE: To evaluate the antibiotic treatment regime in patients with indwelling JJ stents, the benefits and disadvantages of a peri-interventional antibiotic prophylaxis were compared with those of a continuous low-dose antibiotic treatment in a prospective randomised trial. PATIENTS AND METHODS: In all, 95 patients were randomised to either receive peri-interventional antibiotic prophylaxis during stent insertion only (group A, 44 patients) or to additionally receive a continuous low-dose antibiotic treatment until stent removal (group B, 51). Evaluations for urinary tract infections (UTI), stent-related symptoms (SRSs) and drug side-effects were performed before stent insertion and consecutively after 1, 2 and 4 weeks and/or at stent withdrawal. All patients received a peri-interventional antibiotic prophylaxis with 1.2 g amoxicillin/clavulanic acid. Amoxicillin/clavulanic acid (625 mg) once daily was administered for continuous low-dose treatment (group B). Primary endpoints were the overall rates of UTIs and SRSs. Secondary endpoints were the rates and severity of drug side-effects. RESULTS: Neither the overall UTI rates (group A: 9% vs group B: 10%), nor the rates of febrile UTIs (group A: 7% vs group B: 6%) were different between the groups. Similarly, SRS rates did not differ (group A: 98% vs group B: 96%). Antibiotic side-effect symptoms were to be increased in patients treated with low-dose antibiotics. CONCLUSION: A continuous antibiotic low-dose treatment during the entire JJ stent-indwelling time does not reduce the quantity or severity of UTIs and has no effect on SRSs either compared with a peri-interventional antibiotic prophylaxis only.

Occlusion of seminal vesicles increases sexual activity in a mouse model.

BACKGROUND: Little is known about the physiologic role of seminal vesicles beyond their fertility function. It has been suggested repeatedly that seminal vesicles have an impact on sexual activity. Although this has been investigated in various animal models, such a role has never been found. OBJECTIVE: To assess in a novel mouse model whether occlusion of seminal vesicles affects sexual activity. DESIGN, SETTING, AND PARTICIPANTS: Adult male CD1 mice (n=77) were assigned randomly to the experimental groups: (1) seminal vesicle occlusion (SVO) (n=24), (2) seminal vesicle resection (SVR) (n=23), and (3) sham operation (SO) (n=30). Adult females were brought into estrus by the Whitten effect. After recuperation, mouse pairs were observed during sessions of 3h each. Sexual activity was analyzed separately by three observers blinded to the experimental conditions. INTERVENTION: SVO, SVR, and SO. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was percentage of sessions with intromission; secondary end points were number of intromissions and latency until first intromission. A logistic regression model and the Kruskal-Wallis test were used. RESULTS AND LIMITATIONS: A total of 141 sessions for a total of 423h were analyzed. Intromission was scored in 20 of 42 sessions (48%) with SVO mice, a significantly higher rate than the 8 of 39 sessions (21%) with SVR mice (p=0.001) and 18 of 60 sessions (30%) with SO mice (p=0.004). Secondary end points were comparable in all three groups (p=0.303 and 0.450, respectively). CONCLUSIONS: Males with SVO were significantly more often sexually active than males undergoing SVR or SO. This suggests that occluded, and thus engorged, seminal vesicles increase sex drive in male mice. Since the potential clinical benefit might be highly relevant, further studies should confirm these promising results and investigate the potential application in men.

Is bilateral extended pelvic lymphadenectomy necessary for strictly unilateral invasive bladder cancer?

PURPOSE: We determined the necessary extent of pelvic lymph node dissection in patients with strictly unilateral bladder cancer. MATERIALS AND METHODS: A total of 40 patients with cystectomy and unilateral bladder cancer preoperatively underwent flexible cystoscopy guided injection of radioactive technetium into the contralateral bladder wall. Preoperatively single photon emission computerized tomography was done in all cases to detect and localize radioactive lymph nodes. Radioactive lymph nodes were confirmed intraoperatively by a γ probe and removed separately. Backup extended pelvic lymph node dissection and ex vivo examination of the whole specimen with a γ camera were done to preclude missed radioactive lymph nodes. Single photon emission computerized tomography and intraoperative findings were used to generate a 3-dimensional projection model of each lymph node site. RESULTS: A total of 228 radioactive lymph nodes (median 6, range 1 to 17) were detected, including 193 (85%) on the ipsilateral side of injection and 35 (15%) on the contralateral side. Of the contralateral lymph nodes 6%, 5% and 4% were in the external iliac, obturator fossa and common iliac region, respectively, but none were in the contralateral internal iliac region. At least 1 radioactive lymph node per patient was detected on the ipsilateral side. Additional lymphatic drainage to the contralateral side was found in 40% of patients. CONCLUSIONS: Crossover lymphatic drainage is a common phenomenon and unilateral pelvic lymph node dissection would have missed radioactive lymph nodes in 40% of patients. However, we noted no lymphatic drainage to the contralateral internal iliac region. Thus, when bladder tumors are strictly unilateral, contralateral pelvic lymph node dissection can be limited to the obturator fossa, and the external and common iliac regions. Consequently preserving the contralateral autonomic nerves situated close to the internal iliac vessels does not compromise surgical radicality.

Role and extent of lymphadenectomy during radical cystectomy for invasive bladder cancer.

There is substantial variability in the extent of the node dissection performed during radical cystectomy for bladder cancer. Here, we review the diagnostic assessment of lymph node metastasis and the prognostic and therapeutic benefit for pelvic node dissection for bladder cancer. A review of the applicable urologic literature regarding the topics of lymphadenectomy for bladder cancer was conducted. Nodal metastasis above a limited or standard template is not uncommon, with up to 16% of all nodal metastasis detected proximal to the aortic bifurcation. However, skip metastasis is extremely rare. Proteins associated purely with epithelial tissue such as cytokeratin (CK)-19, CK-20, and uroplakin II have been observed in reportedly negative nodal specimens, which indicates that routine microscopic analysis of nodal tissue may miss small foci of metastatic cancer. In addition to the surgical technique, the total number of lymph nodes removed is influenced by patient anatomy and pathologic processing and therefore may be unsuitable as a procedural quality statement. Consecutively, meticulous removal of tissue within a defined and uniformly applied template may be more relevant than absolute nodal count. Observational cohort series indicate an improved oncologic outcome for patients undergoing extensive nodal dissection. The results of two randomized controlled trials addressing the extent of nodal dissection for bladder cancer are forthcoming.

Validation of a novel robotic-assisted partial nephrectomy surgical training model.

UNLABELLED: What's known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic-assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic-assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training. OBJECTIVE: To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic-assisted partial nephrectomy (RAPN). METHODS: We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (≥100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post-study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey-kramer test. RESULTS: The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as 'very realistic' (median visual analogue score 7/10) (face validity). Experts also rated the model as an 'extremely useful' training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P = 0.0002) as well as individual metrics, including 'depth perception,''bimanual dexterity,''efficiency,''tissue handling,''autonomy,''precision,' and 'instrument and camera awareness' (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05). CONCLUSION: Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.

Percutaneous radiofrequency ablation of virtual tumours in canine kidney using Global Positioning System-like technology.

UNLABELLED: What's known on the subject? And what does the study add? We have previously shown that percutaneous radiofrequency ablation guided by image-fusion technology allows for precise needle placement with real time ultrasound superimposed with pre-loaded imaging, removing the need for real-time CT or MR guidance. Emerging technology also allows real-time tracking of a treatment needle within an organ in a virtually created 3D format. To our knowledge, this is the first study utilising a sophisticated ultrasound-based navigation system that uses both image-fusion and real-time probe-tracking technologies for in-vivo renal ablative intervention. OBJECTIVES: • To evaluate the feasibility, accuracy and efficacy of ultrasonography (US)-guided percutaneous radiofrequency ablation (RFA) in the canine kidney model using novel Global Positioning System-like probe tracking technology. • Virtual tumours in the canine kidney were ablated in vivo by percutaneous RFA guided exclusively by two-dimensional (2D) US and a virtual navigation system. MATERIALS AND METHODS: • Gold fiducial markers were inserted into renal parenchyma to serve as centres of virtual tumours. • After capturing 2D US images, navigation software created a three-dimensional planning model of the kidney, and superimposed it onto the live US image. • Percutaneous RFA was guided by multiplanar navigation, showing real-time probe positions within the superimposed images, to treat each virtual tumour with a single treatment. • Navigator software predicted the percentage of tumour treated; treated kidney specimens were examined to evaluate projection and targeting accuracy. RESULTS: • In total, 32 virtual tumours (median diameter 16 mm, range 10-24 mm) were treated in 16 canine kidneys. • Median (range) error between 'fiducial tumour centre' and 'treated area centre' was 1.8 (0-25) mm. • Targeting accuracy improved with experience: median (range) error decreased from 6.3 (2-25) mm in an initial 12 tumours to 1.3 (0-9.0) mm in the last 20 tumours (P= 0.008). • The percentage (range) of tumour actually treated improved significantly from the initial series at 23% (0-100%) to 100% (51-100%) (P < 0.001). • Overall, navigator-reported and pathologically confirmed treatment percentages were correlated significantly (r= 0.5; P= 0.006). CONCLUSIONS: • Percutaneous renal RFA guided exclusively by real-time 2D US with multiplanar Global Positioning System-like probe tracking is feasible and accurate. • Near-future technologies, including elastic fusion overlay and anticipation of soft-tissue deformation, will further augment this guidance system.