Innovative training modality for sacral neuromodulation (SNM): Patient-specific computerized tomography (CT) reconstructed 3D-printed training system: ICS School of Modern Technology novel training modality.

INTRODUCTION: Sacral neuromodulation (SNM) is an effective treatment of urinary and bowel dysfunction, including secondary to neurological disorders. The learning curve for the optimal electrode placement for SNM is steep, expensive, and limited by patient factors such as obesity and previous injuries. We aim to create a patient specific 3-dimensional (3D) model for successful SNM training. MATERIALS AND METHODS: A total of 26 urology residents who had different level of knowledge and experience were enrolled to the 3D SNM training program. The creation of 3D sacrum model has been started with evaluation of real patient computerized tomography images and creation of Digital Imaging and Communications in Medicine files. The segmented anatomic structures from the files then edited and stereolithographic files were generated for 3D-model prints via Mimics© software. The 3D-printed models were used for training and evaluation of participants during the SNM intervention was performed. The evaluation of 3D SNM model training was led by one mentor who is expert on SNM. RESULTS: On the preprinted 3D sacrum model all 26 participants were requested to perform the essential steps to complete a SNM procedure and individual procedure time was recorded. The mean and median scores were 18.8 and 19, respectively according to Likert scores (min 11 max 28). CONCLUSIONS: SNM is increasing in popularity as a treatment option with physicians and patients with refractory symptoms. Few experienced specialists exist, and more effective training methods are needed to tackle the increasing demand, and individual patient anatomy.

Urologic Surgery in Digital Era: Foresights and Futuristic Approach.

The new scientific developments and technological opportunities that have led to significant changes all build up the digital era. In medicine, the use of new technologies in patient diagnosis and treatment processes has opened new horizons for physicians and patients. As considering for the medical training, 3-dimensional modeling opportunities, virtual reality, augmented reality, and various simulators offered by the new technologies of the digital era have become a new hope. The 3-dimensional scanning and modeling, 3-dimensional medical printing, virtual reality technologies applications and simulators in urology are very recent and valuable. Besides, the exoscope-assisted 3-dimensional open surgery provides high-resolution 3-dimensional images to surgeons with high comfort as compared with old-fashioned operating microscopes. New modalities that tried to be integrated in robotic surgery are 3-dimensional reconstruction, usage of indocyanine green, augmented reality, contrast ultrasound, haptic feedback, and availability of single port. Some new companies announced their new robotic systems in the market. The use of these new technological applications during medical training, especially at the beginning of the education curve for various surgical interventions, may be beneficial in terms of reducing possible complications that may be encountered due to inexperience at the beginning of the education process and increasing patient safety. Urology will also stay at the futuristic approach in medicine, while 3-dimensional technologies used more widely in this field.

The examination of the nephroprotective effect of montelukast sodium and N-acetylcysteine in renal ischemia with dimercaptosuccinic acid imaging in a placebo-controlled rat model.

PURPOSE: To determine the nephroprotective effect of NAC and Montelukast Sodium administration against the development of renal damage associated with long warm renal ischemia. METHODS: Twenty-seven rats were randomly divided into 3 study groups, which received NAC, montelukast and placebo, and 3 rats were included in the sham-treated control group. Medications were given 3 days before the procedure. DMSA renal scintigraphy was performed before and after surgery. The right renal pedicle was occluded for 45 min to induce ischemia and then subjected to reperfusion for 6 h (I/R groups). RESULTS: On pathological examination, the mean pathological scores of the montelukast and NAC groups were significantly lower than those of the placebo group. (p <0.05). In biochemical examination, significant differences were found in all parameter levels between the placebo group and the montelukast and NAC groups. (p <0.05) When postoperative DMSA renal scintigraphy measurements and renal function levels were compared, significant differences were found between the montelukast and NAC groups and the placebo and sham groups. CONCLUSION: The administration of NAC and montelukast sodium was seen to have a nephroprotective effect against the development of renal damage associated with warm renal ischemia.

Current status of uro-oncology training during urology residency and the need for fellowship programs: An international questionnaire study.

OBJECTIVE: This study aimed to evaluate the opinions of urologists from different countries about uro-oncology education, fellowship programs, and approaches to different urological malignancies at different stages using a questionnaire. MATERIAL AND METHODS: A total of 207 urologists from 22 countries were sent a questionnaire containing 18 items by email. The questions were related to urologic oncology training provided during residency, acceptance of uro-oncology as a sub-branch, the necessity of certification for treatment and follow-up, fellowship program preferences, adequateness of the programs, and approach differences to the different stages of urological malignancies among the urologists from different countries. RESULTS: In total, 111 (53.62%) urologists who completed the questionnaire were enrolled in the study, and 40.54% of the urologists reported that the uro-oncology training during the residency period was not sufficient. Furthermore, 79.27% of the urologists reported opinions about acceptance of uro-oncology as a sub-branch. The ratio of urologists who undertake the treatment of patients with muscle-invasive bladder cancer (radical surgery and urinary diversion) and prostate cancer (radical prostatectomy, definitive radiation therapy, experimental local treatment, and hormonal therapy) is 27.92% and 37.83%, respectively. The urologists reported that they perform nephron-sparing surgery (NSS), radical nephrectomy (RN), and laparoscopic NSS/RN treatments in patients with localized renal cancer at the rates of 61.26%, 47.74%, and 25.22%, respectively. CONCLUSION: Uro-oncology training during the residency period seems to be inadequate in most of the countries, and a high number of the urologists tend to avoid high-volume operations and systemic treatments of uro-oncologic malignancies.

Technology-based management of neurourology patients in the COVID-19 pandemic: Is this the future? A report from the International Continence Society (ICS) institute.

Coronavirus disease-2019 (COVID-19) pandemic significantly altered our daily life as well as our professional practice. COVID-19 has disrupted our lives both professionally and personally. We know the urological management in a neurogenic patient needs to be tailored to the individual circumstances, this is even more pertinent during these uncertain times. International Continence Society is the premier international organization in functional urology. Lately, it has established an institute to facilitate teaching and training opportunities all over the world. The School of Neurourology teamed with the School of Modern Technology and set up a Webinar-"How to manage the neuro-urological patients in the current pandemic." This was set up as a case-based discussion to deliberate the management of our patients in the present climate and examine the role of modern technology in overcoming the current barriers.

Evaluation of a 3D printed female anatomical model for the hands on training of trans-obturator tape (TOT) and tension free vaginal tape (TVT) sling procedures / Evaluación de un modelo anatómico femenino impreso en 3D para el entrenamiento práctico de los procedimientos de cinta trans-obturadora (TOT) y cinta vaginal sin tensión (TVT)

Trans-obturator tape (TOT) and tension free vaginal tape (TVT) procedures are efficient treatment options, which reduce the surgical complications and provide adequate support to urethra in case of increased abdominal pressure to prevent stress urinary incontinence (SUI). The aim of this study is to evaluate the effect and efficacy of 3D printed female anatomical model on the training of TOT and TVT procedures. A 3D printed female anatomical model was produced for MedTRain3DModSim, Erasmus+ European Union project led by Turkey with the participation of Greece, Italy, Czech Republic and South Korea. Face and content validities of the model evaluated by the participants and the experts respectively. During two learning & teaching & training activities and a multiplier event of the project between 2016 and 2018; 41 medical students, 30 residents and 19 specialists of urology and gynecology were educated and performed TOT and TVT procedures with this model under the mentorship of 3 experts. All participants were assessed and scored for their achievement on both procedures with model according to 7 parameters by the experts. There was no statistical difference between the students and residents for each parameter. All the parameters of the students and specialists were statistically different. 3D anatomical models produced from real data and mimicking different types of tissues are suitable for basic anatomy education of students and residents, hands on training for junior surgeons before cadaveric courses in hybrid education system, surgical planning of the surgeons and informing the patients before the operation.

Los procedimientos de cinta transobturadora (TOT) y cinta vaginal sin tensión (TVT) son opciones de tratamiento eficientes, que reducen las complicaciones quirúrgicas y proporcionan un soporte adecuado a la uretra en caso de aumento de la presión abdominal para prevenir la incontinencia urinaria de esfuerzo (IUE). El objetivo de este estudio fue evaluar el efecto y la eficacia del modelo anatómico femenino impreso en 3D en el entrenamiento de los procedimientos TOT y TVT. Se produjo un modelo anatómico femenino impreso en 3D para MedTRain3DModSim, proyecto Erasmus + de la Unión Europea dirigido por Turquía con la participación de Grecia, Italia, la República Checa y Corea del Sur. Validez facial y de contenido del modelo fueron evaluados por los participantes y los expertos respectivamente. Durante dos actividades de aprendizaje, enseñanza y capacitación y un evento multiplicador del proyecto entre 2016 y 2018; 41 estudiantes de medicina, 30 residentes y 19 especialistas en urología y ginecología fueron capacitados y realizaron procedimientos TOT y TVT de este modelo bajo la tutoría de 3 expertos. Todos los participantes fueron evaluados y calificados por los expertos, por su logro en ambos procedimientos con el modelo de acuerdo con 7 parámetros. No hubo diferencia estadística entre los estudiantes y los residentes para cada parámetro. Todos los parámetros de los estudiantes y especialistas fueron estadísticamente diferentes. Los modelos anatómicos en 3D producidos a partir de datos reales e imitando diferentes tipos de tejidos son adecuados para la educación básica de anatomía de estudiantes y residentes. Además de ofrecer una capacitación práctica para los cirujanos antes de los cursos cadavéricos en el sistema educativo, y una planificación quirúrgica de los cirujanos e información para los pacientes antes de la cirugía.

The examination of the nephroprotective effect of montelukast sodium and N-acetylcysteine in renal ischemia with dimercaptosuccinic acid imaging in a placebo-controlled rat model

Abstract Purpose To determine the nephroprotective effect of NAC and Montelukast Sodium administration against the development of renal damage associated with long warm renal ischemia. Methods Twenty-seven rats were randomly divided into 3 study groups, which received NAC, montelukast and placebo, and 3 rats were included in the sham-treated control group. Medications were given 3 days before the procedure. DMSA renal scintigraphy was performed before and after surgery. The right renal pedicle was occluded for 45 min to induce ischemia and then subjected to reperfusion for 6 h (I/R groups). Results On pathological examination, the mean pathological scores of the montelukast and NAC groups were significantly lower than those of the placebo group. (p <0.05). In biochemical examination, significant differences were found in all parameter levels between the placebo group and the montelukast and NAC groups. (p <0.05) When postoperative DMSA renal scintigraphy measurements and renal function levels were compared, significant differences were found between the montelukast and NAC groups and the placebo and sham groups. Conclusion The administration of NAC and montelukast sodium was seen to have a nephroprotective effect against the development of renal damage associated with warm renal ischemia.

Review of the effect of 3D medical printing and virtual reality on urology training with 'MedTRain3DModsim' Erasmus + European Union Project

Background/aim: It is necessary to incorporate novel training modalities in medical education, especially in surgical fields, because of the limitations of cadaveric training. Traditional medical education has many drawbacks, such as residency working hour restrictions, patient safety conflicts with the learning needs, and the lack of hands-on workshops. The MedTRain3DModsim Project aimed to produce 3-dimensional (3D) medical printed models, simulations, and innovative applications for every level of medical training using novel worldwide technologies. It was aimed herein to improve the interdisciplinary and transnational approaches, and accumulate existing experience for medical education, postgraduate studies, and specialty training. Materials and methods: This project focused on models of solid organs and the urinary system, including the kidney, prostate, ureter, and liver. With 3D medical printing, it is possible to produce a body part from inert materials in just a few hours with the standardization of medical 3D modeling. Results: The target groups of this project included medical students and residents, graduate students from engineering departments who needed medical education and surgical training, and medical researchers interested in health technology or clinical and surgical an atomy. Conclusion: It was also intended to develop a novel imaging platform for education and training by reevaluating the existing data using new software and 3D modalities. Therefore, it was believed that our methodology could be implemented in all related medical fields.

Cadaveric anatomy and dissection in surgical training.

Detailed knowledge of anatomy is an essential part of surgical practice. However, there are many drawbacks in anatomy education that make many residents feel inadequate when they start performing surgeries. Cadaveric dissection courses aim to close the gap between the anatomic knowledge and surgical practice. This review focuses on the role of cadaveric dissection on surgical education, and additionally states the panel decision of the Surgical Anatomy and Technologies Association on the proper use of cadavers.

The effect of cadaveric hands-on training model on surgical skills and confidence for transobturator tape surgery

Objective: To demonstrate the role of cadaveric hands-on training model on surgical skills and confidence levels of surgeons during transobturator tape (TOT) surgery. Material and Methods: A pre-test and post-test evaluation to measure skills during the practice of the steps of TOT surgery was performed on a total of 15 postgraduate urologists and gynecologists during a urogynecologic cadaveric dissection course. The course was shaped with regard to theoretical lessons, full pelvic cadaveric dissection and TOT surgery on cadavers. Results: Good handling of the TOT needle, identifying the right place for groin incision, adequate size of groin incision, identifying the right place for incision at the anterior vagina, dissection of bladder pillars from the vagina, identifying the right place at the vaginal foramina for TOT needle exit, and good placement of mesh were reviewed. The post-test scores were statistically significant for all parameters and also for self confidence level (p<0.001). Conclusion: Cadaveric workshops are important landmarks of surgical education to improve surgical skills, and gain experience and confidence.

Effects of Psychological Status on The Oxidation Parameters of Semen and Blood in Azoospermic Men.

PURPOSE: In limited number of studies performed concerning the psychological moods of female, and male with the diagnosis of infertility, data related to increased incidence of depression, and anxiety have been reported. The objective of this study is to determine whether azoospermia has any psychological effects on men, and investigate the potential effects of psychological mood on seminal, and plasma oxidative parametres. MATERIALS AND METHODS: Twenty-seven patients whose two consecutive semen analyses were reported as pellet -negative azoospermia constituted the azoospermic group, and 30 healthy individuals who applied to the infertility polyclinic with normal seminal parametres comprised the normozoospermic group. RESULTS: BECK Anxiety scores were significantly higher in the azoospermic group (P = 0.009). When compared with the normozoospermic group, higher levels of oxidative parametres, but lower levels of the antioxidative parametre were detected in the azoospermic group (P < 0.05). In the azoospermic group, a positive correlation was detected between BECK Anxiety and total oxidant status. Anxiety may increase oxidative parametres in both plasma, and seminal fluid (r = 473, p = 0.026). CONCLUSION: Anxiety may increase oxidative parametres in both plasma, and seminal fluid. Oxidative milieu may impair sperm quality, and affect the success rates of assisted reproductive treatments. The determination of oxida-tive potential in infertile men, thiol, and prolidase may be used as biomarkers.

Anatomic structure of the internal iliac artery and its educative dissection for peripartum and pelvic hemorrhage.

The abdominal aorta is divided into two parts (right and left) at the level of the fourth-fifth lumbar vertebra and called the common iliac artery. Anterior to the sacroiliac joint, common iliac arteries are divided into external and internal iliac arteries. The external iliac artery supplies the lower limb, and the internal iliac artery is the major vascular supply of the pelvis. Internal iliac artery is divided into anterior and posterior trunk. The anterior trunk supplies the pelvis, visceral organs, and the posterior trunk supplies pelvic parietal structures. The broad ligament envelopes the uterus anteriorly and posteriorly with its sheets and continues as the pelvic peritoneum at the lateral side of the pelvic wall. After cutting the pelvic peritoneum, the retroperitoneal area is visualized and the internal iliac artery with other great vessels of the abdomen can be noted.

Basic clinical retroperitoneal anatomy for pelvic surgeons.

Basic anatomical knowledge should be improved during residency period with clinical practice. Especially pelvic surgeons; obstetricians, gynecologists, gynecological oncologists, urologists and general surgeons must have an advanced level practise of retroperitoneal anatomy to gain surgical skills. Retroperitoneal topographic anatomy, retroperitoneal vasculature, ureteric dissection and pelvic avascular spaces are the precise points during pelvic surgery.

Novel Anatomic Mapping of Pelvic Plexus at Prostatic and Periprostatic Region on Fresh Frozen Cadaveric Setting.

PURPOSE: We aimed to investigate the exact localization of neural pathway and the frequency of nerve fibers, which are located in the pelvic facial layers in the prostate and periprostatic regions. MATERIALS AND METHODS: We used four fresh frozen cadavers in this trial. Anatomical layers of anterior rectus fascia and abdominal rectus muscle were dissected to reach the retropubic area. Prostate, visceral and parietal pelvic fascia, levator ani muscle and puboprostatic ligaments were identified. Nine tissue samples, each 1x1 cm in size, were obtained from each cadaver and grouped separately. The locations of these samples are as follows. Group G I from 12 o'clock (apical region), G II from right prostatic apex, G III from 2 o'clock, G IV from right far pelvic lateral, G V from 5 o'clock, G VI from 7 o'clock, GVII from left far pelvic lateral, G VIII from 10 o'clock and G IX from left prostatic apex. Nerve distribution, frequency and diameters of these 9 groups were compared to each other. RESULTS: 36 specimens were obtained from 4 cadavers. Mean number of nerve fibers was 14.1. The number of nerve fibers in each location were not statistically different from each other (P = .9). Mean nerve diameter was 89.1 µm. Mean diameter of nerves was statistically different between groups II, III IV and VI and VIII (P = .001). No difference was seen amongst others. CONCLUSION: The distributions of nerve fibers at prostate and peri-prostatic region were homogeneous while the nerve diameters varied amongst the different regions.

What is new in non-muscle-invasive bladder cancer in 2016?

Approximately 75% of bladder cancers are non-muscle-invasive bladder cancer (NMIBC), and 50% of NMIBC patients who are treated with transurethral resection (TUR) have a recurrence of the disease and 5-25% of these patients progressed to muscle-invasive disease after repeated recurrences. NMIBC patients receive various treatments aimed at reducing disease recurrence and progression. Although the recurrence rate of disease remains above target, thus increasing treatment cost, the true rate of recurrence after the primary surgery is controversial. Recurrences can be categorized as either true recurrence due to aggressive tumor biology and implantation of floating cancer cells or false recurrence such as small, flat, or carcinoma in situ lesions overlooked in the primary procedure. Here we discuss new diagnostic methods and treatment options to improve outcomes and reduce recurrence rates in NMIBC.

Medical management in locally advanced and metastatic prostate cancer: Does changes in treatment policy have any specific effect on PSA levels?

OBJECTIVE: Androgen deprivation therapy (ADT) is commonly used as a first-line treatment for locally advanced and metastatic prostatic cancer (Pca). There is no consensus about which alternative treatment should be used after the failure of initial ADT. We aimed to investigate the effect of changes in treatment on PSA and testosterone levels. MATERIAL AND METHODS: A total of 120 patients with an established diagnosis of either locally advanced or metastatic Pca in two different centers. Depending on the type of medical and/or surgical management protocol planned at initial presentation, all cases were divided into three main groups as follows. Group 1 (n: 80) included the patients who underwent medical management during whole follow-up period in whom the initial management protocol was later on switched to another medical treatment with different agents, Group 2 (n: 20) included patients who were initially treated with a medical management protocol and switched to surgical castration during follow-up evaluation and lastly Group 3 (n: 20) included the patients undergoing treated surgical castration as initial treatment modality without any further medical management protocol. RESULTS: Evaluation of our data did clearly demonstrate a statistically significant difference between the initial and final PSA as well as testosterone levels in Group 1 cases. Mean PSA and testosterone levels increased significantly in these cases despite a change in hormonal therapy by using another agent for androgen deprivation. Cases in Group 2 and 3 cases did not show any statistically significant difference with respect to the mean PSA as well as testosterone values during the same follow-up period. CONCLUSIONS: Our data clearly indicated that in case of a biochemical progression, switching into another alternative medical treatment was not effective enough in limiting the rising PSA levels in a statistically significant manner when compared with the approaches of switching to surgical castration after initial medical treatment or continuing with regular and close follow-up after initial surgical castration alone.

Ultrastructural analyses of the novel chimeric hemostatic agent generated via nanotechnology, ABS nanohemostat, at the renal tissue level.

Ankaferd Blood Stopper (ABS), a hemostatic agent of plant origin, has been registered for the prevention of clinical hemorrhages. Currently there is no data regarding the ultrastructural analysis of ABS at the tissue level. The aim of this study is to assess renal tissue effects via scanning electron microscopy (SEM) analyses for the ABS and ABS nanohemostat (formed by the combination of self-assembling peptide amphiphile molecules and ABS). SEM experiments were performed with FEI Nova NanoSEM 230, using the ETD detector at low vacuum mode with 30 keV beam energy. SEM analyses revealed that significant erythroid aggregation are present inside the capillary bed of the renal tissue. However, neither the signs of necrosis nor any other sign of tissue damage are evident in the surrounding renal tissue supplied by the microcapillary vasculature. Our study is important for several reasons. Firstly, in our study we used ABS nanohemostat which was recently developed. This study adds valuable information to the literature regarding ABS nanohemostat. Secondly, this study is the first ultrastructural analysis of ABS that was performed at the tissue level. Thirdly, we disclosed that ABS nanohemostat could induce vital erythroid aggregation at the renal tissue level as detected by SEM. Lastly, we detected that ABS nanohemostat causes no harm to the tissues including necrosis and any other detrimental effects.