Could trainees' finger placement at the surgeon's console affect overall outcomes of robotic surgery in radical prostatectomy? A prospective, blinded, robotic simulation pilot study.

INTRODUCTION: Robotic surgery for localized prostate cancer offers a greater range of motion attributed to the EndoWrist instruments. Postoperative outcomes are linked to the quality of vesico-urethral anastomosis. Trainees frequently complain of suturing difficulty in a back-handed fashion. We aimed to analyze wrist motion using the DaVinci simulator. We hypothesized that using the thumb and index finger would allow superior surgical proficiency when compared to the middle finger. METHODS: After institutional review board approval, we recruited 42 medical students in one academic medical center. Students were randomly assigned to start with their thumb and index finger (1&2) or thumb and middle finger (1&3). Three standardized modules were used with nine metrics calculated, including: score, total time, economy of motion, efficiency score, collisions, inaccurate puncture, wound approximation, out of view, and penalty subtotal. Statistical analysis of the metrics was calculated using SPSS. RESULTS: Three metrics were found to have differences between the finger placement of 1&3 compared to 1&2. The number of collisions, wound approximation, and penalty score where 1&3 were used had a lower score in each. The number of collisions was 5.7 less in the 1&3 finger placement (p=0.046). This metric was found to have statistically significant differences between finger placement where 1&3 had a lower score compared to 1&2. The wound approximation score was 0.2 points lower when using the 1&3 placement (p=0.075). Lastly, the penalty assigned was 6.5 points lower when using 1&3 (p=0.069). CONCLUSIONS: Although finger placement did not affect the overall score of the completed simulation, instrument collisions and unnecessary wound complications may lead to adverse outcomes when using 1&2 despite offering a wider range of motion. This may be due to decreased comfort in hand position. Trainees may be able to improve the effectiveness of their vesico-urethral anastomosis during robotic-assisted radical prostatectomy.

Current advances in pain regimens for percutaneous nephrolithotomy A comprehensive review.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) causes pain and discomfort after surgery. The primary causes of immediate postoperative pain after PCNL are visceral pain from the ureters and kidneys, and body surface discomfort from incisions. Acute, untreated pain has the potential to develop into chronic pain, which remains a considerable burden for the rehabilitation of patients. The goal of this review was to describe the current options for treating pain post-PCNL. METHODS: We conducted a literature review of all published manuscripts on pain protocols for patients undergoing PCNL and related topics; 50 published manuscripts were identified and reviewed. RESULTS: PCNL morbidity must be reduced by an appropriate management of postoperative pain. Opioids, multimodal therapy, tubeless PCNL, reduced size of nephrostomy tube, and regional anesthesia are currently available for reducing postoperative pain. CONCLUSIONS: Implementing successful treatment strategies for postoperative pain after PCNL is key in reducing the morbidity and mortality of PCNL.

Ureteral stenting in the clinic: a safe and cost-effective alternative to the operating room.

PURPOSE: Ureteral stent placement is one of the most common procedures performed by urologists, and is typically done in the operating room. At Ochsner-LSU Health Shreveport, urologists have a unique setting allowing them to place ureteral stents for patients present in the outpatient ambulatory clinic without the need for nitrous oxide. This allows patients to avoid being admitted to the hospital and receiving subsequent general anesthesia in the operating room. Therefore, our novel study evaluates the feasibility, safety, and cost-effectiveness of ureteral stents insertion in the clinic. MATERIAL AND METHODS: In this study, we analyzed 240 patients with a total of 279 different ureteral stent insertion encounters to evaluate the safety and costs of stenting in the clinic compared to the operating room. Stents were placed in the outpatient clinic for 126 patients, which required either a new ureteral stent insertion or a scheduled stent exchange. RESULTS: Overall, there was an increased age and length of stent duration among those who were stented in the clinic. We did not observe any increase in narcotics use, pain, adverse injuries, or differences in stent length. The total cost of a stent insertion operating room was $16,349.91 whereas the clinic procedure cost $7,865.69, however: medicare reimbursement remained the same. CONCLUSION: Our findings demonstrate a novel use of stenting in the clinic is feasible as an outpatient alternative. It is a safe alternative to the operating room, and more cost-effective.

ChatGPT's Ability to Assess Quality and Readability of Online Medical Information: Evidence From a Cross-Sectional Study.

Introduction Artificial Intelligence (AI) platforms have gained widespread attention for their distinct ability to generate automated responses to various prompts. However, its role in assessing the quality and readability of a provided text remains unclear. Thus, the purpose of this study is to evaluate the proficiency of the conversational generative pre-trained transformer (ChatGPT) in utilizing the DISCERN tool to evaluate the quality of online content regarding shock wave therapy for erectile dysfunction. Methods Websites were generated using a Google search of "shock wave therapy for erectile dysfunction" with location filters disabled. Readability was analyzed using Readable software (Readable.com, Horsham, United Kingdom). Quality was assessed independently by three reviewers using the DISCERN tool. The same plain text files collected were inputted into ChatGPT to determine whether they produced comparable metrics for readability and quality. Results The study results revealed a notable disparity between ChatGPT's readability assessment and that obtained from a reliable tool, Readable.com (p<0.05). This indicates a lack of alignment between ChatGPT's algorithm and that of established tools, such as Readable.com. Similarly, the DISCERN score generated by ChatGPT differed significantly from the scores generated manually by human evaluators (p<0.05), suggesting that ChatGPT may not be capable of accurately identifying poor-quality information sources regarding shock wave therapy as a treatment for erectile dysfunction. Conclusion ChatGPT's evaluation of the quality and readability of online text regarding shockwave therapy for erectile dysfunction differs from that of human raters and trusted tools. Therefore, ChatGPT's current capabilities were not sufficient for reliably assessing the quality and readability of textual content. Further research is needed to elucidate the role of AI in the objective evaluation of online medical content in other fields. Continued development in AI and incorporation of tools such as DISCERN into AI software may enhance the way patients navigate the web in search of high-quality medical content in the future.

A Retrospective Review of Bovine Artery Graft Patency: A Single-Site Study.

BACKGROUND: The hemodialysis-dependent population is increasing in the United States. Dialysis access complications are a significant source of morbidity and mortality for patients with end-stage renal disease. A surgically created autogenous arteriovenous fistula has been the gold standard for dialysis access. However, for patients who are not candidates for arteriovenous fistula, arteriovenous grafts using various conduits have widely been used. In this study, we report the outcomes of bovine carotid artery (BCA) grafts for dialysis access at a single institution and compare these results to those for polytetrafluoroethylene (PTFE) grafts. METHODS: A single-institution, retrospective review of all patients undergoing surgical placement of a bovine carotid artery graft for dialysis access from 2017-2018 was performed under an institutional review board-approved protocol. The primary, primary-assisted, and secondary patency were calculated for the whole cohort and results determined based on gender, body mass index (BMI), and indication for use. Comparison was performed to PTFE grafts at same institution from 2013 to 2016. RESULTS: One hundred and twenty two patients were included in this study. Seventy four patients had a BCA graft placed while 48 had a PTFE graft placed. . The mean age was 59.7 ± 13.5 years in the BCA group, 55.8 ± 14.5 in the PTFE group, and the mean BMI was 29.8 ± 9.2 kg/m2 in the BCA group and 28.1 ± 9.7 in the PTFE group. Comparison of the comorbidities present in BCA/PTFE groups included hypertension (92%/100%), diabetes (57%/54%), congestive heart failure (28%/10%), lupus (5%/7%), and chronic obstructive pulmonary disease (4%/8%). The various configurations were reviewed (BCA/PTFE): interposition/access salvage (40.5%/13%), axillary-axillary (18.9%, 7%), brachial-basilic (5.4%, 6%), brachial-brachial (4.1%, 4%), brachial-cephalic (1.4%, 0%), axillary-brachial (1.4%, 0%), brachial-axillary (23%, 62%), and femoral-femoral (5.4%, 6%). Overall, 12-month primary patency was 50% in the BCA group and 18% in the PTFE group (P = 0.001). Twelve-month primary-assisted patency was 66% in the BCA group and 37% in the PTFE group (P = 0.003). Twelve-month secondary patency was 81% in the BCA group and 36% in the PTFE group (P = 0.07). When comparing BCA graft survival probability among male and female gender, males had better primary-assisted patency (P = 0.042). Secondary patency among the 2 genders was similar. There was no statistically significant difference in primary, primary-assisted, and secondary patency of BCA grafts between different BMI groups and indication for use. The average patency of a bovine graft was 17.8 ± 8 months. Sixty one percent of the BCA grafts needed intervention with 24% needing multiple interventions. There was an average of 7 ± 5 months to first intervention. The infection rate was 8.1% in the BCA group and 10.4% in the PTFE group with no statistical difference. CONCLUSIONS: Primary and primary-assisted patency rates at 12 months in our study were higher than those for PTFE at our institution. There was higher primary-assisted patency of BCA grafts among males at 12 months compared to PTFE. Obesity and indication for BCA graft use did not appear to affect patency in our population.

SARS-CoV-2 Effects on the Male Genitourinary System.

SARS-CoV-2 infection arose in 2019 and has changed life as we know it. With our ever-advancing knowledge, therapies, and vaccines, more functions of the SARS-CoV-2 virus are being investigated outside of its pulmonary invasion. Here, we set out to review the current and pertinent literature on the impact of SARS-CoV-2 on the male genitourinary system including the bladder, lower urinary tract, prostate, testis, and penis. The biggest newsworthy stake was if SARS-CoV-2 could be transmitted through semen. Although initially thought to occur, more recent studies have opposed this hypothesis. Outside of the reproductive spread of SARS-CoV-2, multiple studies in this review highlight where the virus resides and what effect it may be having on this genitourinary system including increased voiding problems, viral persistence months after systemic clearance, and rare penile complications post-infection. Long-term outcomes are still needed to fully understand how SARS-CoV-2 infection can alter the genitourinary system.

Do ureteral stent diameter and length or patient demographics play a role in stent encrustation?

INTRODUCTION: Retained ureteral stents may constitute a technical challenge. The purpose of this study was to analyze the patient population with retained ureteral stents with regards to stent sizes to better understand if these factors could play a pivotal role in their encrustation. METHODS: After institutional review board approval, we retrospectively analyzed the data of patients who underwent multimodal surgical procedures for the removal of retained ureteral stents from 2010-2018. The primary outcomes analyzed were ureteral stent length and diameter, location of stent placement, and patients' demographics as potential etiologies for encrustation. RESULTS: We included 30 patients with 32 encrusted ureteral stents and 37 patients with 46 forgotten non-retained ureteral stents. Indications for stenting included urolithiasis, malignancy, pregnancy, ureteral stricture, and ureteropelvic junction obstruction. Stent diameters ranged from 6-8.5 Fr. Stent lengths ranged from 22-30 cm, and multilength stents were used too. Smaller diameter stents were less likely to be retained when compared to larger diameter stents (>6 Fr) (p=0.002). Overall stent length was not found to be significant (p=0.251); however, the difference in stent surface area differed by over 1 cm (p<0.001). Patients who were uninsured were more likely to have retained stents (p=0.003). Patients who reside with longer commuting distance to the main academic medical center were more likely to have retained stents (p=0.010). CONCLUSIONS: Retained ureteral stents could be avoided. Taking into consideration ureteral anatomical variation among patients, smaller diameter stents and smaller surface area may prevent encrustation. Uninsured patients with farther distance to seek medical care and females are the most at risk.

Prostate cancer metastatic to bilateral testicles: case report and literature review.

PURPOSE: Hormone-refractory prostate cancer (PCa) has a high incidence of metastasis with common secondary site locations. Our case report describes a rare metastatic site of PCa infiltrating bilateral testicles in the absence of definitive radiologic evidence. MATERIALS AND METHODS: Following the patient's consent and IRB exemption, we report the clinical, radiological, and pathological presentation of the patient treated at our institution. We also conducted an inclusive literature review of PCa with bilateral testicular metastases. RESULTS: Our patient is a 54-year-old male who presented to the emergency room with lower urinary tract symptoms and failure to void. A full workup including digital rectal examination, PSA (580 ng/ml), and a transrectal ultrasound (TRUS) biopsy performed afterward revealed an adenocarcinoma of the prostate. The metastatic workup at presentation was negative. After failure to comply with treatment guidelines, the patient was referred back to us with bilateral testicular masses. Without clear evidence of the origin of the masses, bilateral orchiectomy was performed, and pathological analysis confirmed it was metastatic prostate adenocarcinoma. Post-orchiectomy, the patient was again lost to follow up. Three years later the patient returns and placed in palliative care. CONCLUSIONS: This case report highlights that PCa can have a highly variable course and progression can occur in the absence of adherence to treatment. Any evidence of disease relapse and clinical suspicion of metastasis should be investigated, especially in patients with advanced and metastatic disease or poor adherence to surveillance protocol.

Primary Renal Carcinoid: Two Rare Cases at a Single Center.

Renal carcinoid tumors are exceedingly rare. These neuroendocrine masses are most frequently found in the gastrointestinal and respiratory tracts. A renal carcinoid tumor has only been documented in around 100 cases. In this article, we report two additional cases in female patients ages 53 and 63. Both tumors were found incidentally on computed tomography scans. Both women underwent radical nephrectomies. Neither has shown evidence of metastasis nor relapse to date; however, the 63-year-old woman was lost to follow-up. In conclusion, upon discovery of the asymptomatic renal mass, renal carcinoid should be a consideration in the differentiation, and if suspected, may be treated with radical nephrectomy as was done in our hospital.

A Systematic Review on the Investigation of SARS-CoV-2 in Semen.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a virus that is present in most bodily fluids. However, whether SARS-CoV-2 is present in the semen remains underexplored. Thus, we systematically reviewed the existing studies on the presence of SARS-CoV-2 in semen. METHODS: A literature search of the PubMed, Embase, Cochrane, Web of Science, Google Scholar, and Ovid databases was performed for articles from the dates of their inception to August 2020 using the following keywords: COVID-19, SARS-CoV2, seminal, semen, and sperm. After excluding non-human studies and articles that were not in the English language, we identified 19 relevant studies. The full text of the articles were reviewed and a total of eight articles remained after applying our selection criteria. RESULTS: After reviewing the presence of SARS-CoV-2 in the eight different studies using semen samples, only one reported the presence of the virus. Six out of 160 total semen samples with SARS-CoV-2 positive demonstrated the presence of viral RNA, of which 2 were from males in the recovery phase and 4 from the acute phase of the infection. CONCLUSION: The novel nature of SARS-CoV-2 has limited the number and size of studies on semen. Nevertheless, the current literature, while limited, has confirmed the presence of SARS-CoV-2 in semen in one out of the eight reported studies and totaling 4.3% of the population screened. Taken together, the risk of the presence of SARS-CoV-2 in semen appears to be extremely low and likely negligible in recovered men. Future studies need to focus on whether complete viral particles can be seen in semen and the possibility of sexual transmission.

FOXA2 promotes prostate cancer growth in the bone.

Bone metastasis frequently occurs in advanced-stage prostate cancer (PCa) patients. Understanding the mechanisms that promote PCa-mediated bone destruction is important for the identification of therapeutic targets against this lethal disease. We found that forkhead box A2 (FOXA2) is expressed in a subset of PCa bone metastasis specimens. To determine the functional role of FOXA2 in PCa metastasis, we knocked down the expression of FOXA2 in PCa PC3 cells, which can grow in bones and elicit an osteolytic reaction. The PC3/FOXA2-knockdown cells generated fewer bone lesions following intra-tibial injection compared to control cells. Further, we found that FOXA2 knockdown decreased the expression of PTHLH, which encodes PTHrP, a well-established factor that regulates bone remodeling. These results indicate that FOXA2 is involved in PCa bone metastasis.

A 22-Year-Old Retained Ureteral Stent: One of the Oldest Removed Using a Multimodal Endourologic Approach.

Background: Ureteral stent encrustation poses a distinct challenge to urologists. The purpose of our study is to present a patient with one of the oldest retained ureteral stents reported in the literature, effectively treated at our institution with a multimodal endourologic approach. Case Presentation: After IRB approval and patient's consent, we present the case of a 47-year-old man who was referred to our institution for gross hematuria and a right retained ureteral stent, incidentally found on imaging. This patient had a history of traumatic stab wound 22 years prior, requiring an exploratory laparotomy and a ureteral stent insertion. Preoperative CT scan revealed a fragmented and heavily encrusted right ureteral stent. The patient was effectively treated with a multimodal endourologic approach, including a cystolitholapaxy, a right retrograde flexible ureteroscopy (URS), and a prone split-leg right percutaneous nephrolithotomy combined with a right retrograde URS. The patient was rendered stone and stent free. Conclusion: To our knowledge, this 22-year-old retained stent is one of the oldest reported in the literature. As observed in our patient, multimodal endourologic techniques are safe and effective in patients with retained ureteral stents to render then stent and stone free.

The expression of YAP1 is increased in high-grade prostatic adenocarcinoma but is reduced in neuroendocrine prostate cancer.

BACKGROUND: After long-term androgen deprivation therapy, 25-30% prostate cancer (PCa) acquires an aggressive neuroendocrine (NE) phenotype. Dysregulation of YAP1, a key transcription coactivator of the Hippo pathway, has been related to cancer progression. However, its role in neuroendocrine prostate cancer (NEPC) has not been assessed. METHODS: Immunohistochemistry and bioinformatics analysis were conducted to evaluate YAP1 expression levels during PCa initiation and progression. RESULTS: YAP1 expression was present in the basal epithelial cells in benign prostatic tissues, lost in low-grade PCa, but elevated in high-grade prostate adenocarcinomas. Interestingly, the expression of YAP1 was reduced/lost in both human and mouse NEPC. CONCLUSIONS: The expression of YAP1 is elevated in high-grade prostate adenocarcinomas but lost in NEPC.

Foxa2 activates the transcription of androgen receptor target genes in castrate resistant prostatic tumors.

Prostate cancer (PCa) is the leading cancer among men. Androgen Deprivation Therapy (ADT) is a common treatment for advanced PCa. However, ADT eventually fails and PCa relapses, developing into castration-resistant prostate cancer (CRPCa). Although alternative pathways such as cancer stem-cell pathway and neuroendocrine differentiation bypass androgen receptor (AR) signaling, AR remains the central player in mediating CRPCa. In this study, we identified a mechanism that retains AR signaling after androgen deprivation. The TRAMP SV40 T antigen transgenic mouse is a model for PCa. The expression of SV40 T-antigen is driven by the androgen-responsive, prostate specific, Probasin promoter. It has been recognized that in this model, T-antigen is still expressed even after androgen ablation. It is unclear how the androgen-responsive Probasin promoter remains active and drives the expression of T-antigen in these tumors. In our study, we found that the expression of Foxa2, a forkhead transcription factor that is expressed in embryonic prostate and advanced stage prostate cancer, is co-expressed in T-antigen positive cells. To test if Foxa2 activates AR-responsive promoters and promotes the expression of T-antigen, we established the prostate epithelial cells that stably express Foxa2, NeoTag1/Foxa2 cells. Neotag1 cells were derived from the Probasin promoter driven SV40 T-antigen transgenic mouse. We found ectopic expression of Foxa2 drives the T-antigen expression regardless of the presence of androgens. Using this model system, we further explored the mechanism that activates AR-responsive promoters in the absence of androgens. Chromatin immunoprecipitation revealed the occupancy of both H3K27Ac, an epigenetic mark of an active transcription, and Foxa2 at the known AR target promoters, Probasin and FKBP5, in the absence of androgen stimulation. In conclusion, we have identified a mechanism that enables PCa to retain the AR signaling pathway after androgen ablation.

Identification of the proteome complement of humanTLK1 reveals it binds and phosphorylates NEK1 regulating its activity.

The Tousled Like kinases (TLKs) are involved in numerous cellular functions, including the DNA Damage Response (DDR), but only a handful of substrates have been identified thus far. Through a novel proteomic screen, we have now identified 165 human proteins interacting with TLK1, and we have focused this work on NEK1 because of its known role in the DDR, upstream of ATR and Chk1. TLK1 and NEK1 were found to interact by coIP, and their binding is strengthened following exposure of cells to H2O2. Following incubation with doxorubicin, TLK1 and NEK1 relocalize with nuclear repair foci along with γH2AX. TLK1 phosphorylated NEK1 at T141, which lies in the kinase domain, and caused an increase in its activity. Following DNA damage, addition of the TLK1 inhibitor, THD, or overexpression of NEK1-T141A mutant impaired ATR and Chk1 activation, indicating the existence of a TLK1>NEK1>ATR>Chk1 pathway. Indeed, overexpression of the NEK1-T141A mutant resulted in an altered cell cycle response after exposure of cells to oxidative stress, including bypass of G1 arrest and implementation of an intra S-phase checkpoint.

Androgen receptor differentially regulates the proliferation of prostatic epithelial cells in vitro and in vivo.

Androgens regulate the proliferation and differentiation of prostatic epithelial cells, including prostate cancer (PCa) cells in a context-dependent manner. Androgens and androgen receptor (AR) do not invariably promote cell proliferation; in the normal adult, endogenous stromal and epithelial AR activation maintains differentiation and inhibits organ growth. In the current study, we report that activation of AR differentially regulates the proliferation of human prostate epithelial progenitor cells, NHPrE1, in vitro and in vivo. Inducing AR signaling in NHPrE1 cells suppressed cell proliferation in vitro, concomitant with a reduction in MYC expression. However, ectopic expression of AR in vivo stimulated cell proliferation and induced development of invasive PCa in tissue recombinants consisting of NHPrE1/AR cells and rat urogenital mesenchymal (UGM) cells, engrafted under renal capsule of adult male athymic mice. Expression of MYC increased in the NHPrE1/AR recombinant tissues, in contrast to the reduction seen in vitro. The inhibitory effect of AR signaling on cell proliferation in vitro were reduced by co-culturing NHPrE1/AR epithelial cells with prostatic stromal cells. In conclusion, these studies revealed that AR signaling differentially regulates proliferation of human prostatic epithelia cells in vitro and in vivo through mechanisms involving stromal/epithelial interactions.