Conservative management for postprostatectomy urinary incontinence

BACKGROUND: Urinary incontinence is common after radical prostatectomy and can also occur in some circumstances after transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods.   OBJECTIVES: To determine the effectiveness of conservative management for urinary incontinence up to 12 months after transurethral, suprapubic, laparoscopic, radical retropubic or perineal prostatectomy, including any single conservative therapy or any combination of conservative therapies.  SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (5 February 2014), CENTRAL (2014, Issue 1), EMBASE (January 2010 to Week 3 2014), CINAHL (January 1982 to 18 January 2014), ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (both searched 29 January 2014), and the reference lists of relevant articles.  SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy.  DATA COLLECTION AND ANALYSIS: Two or more review authors assessed the methodological quality of the trials and abstracted data. We tried to contact several authors of included studies to obtain extra information.  MAIN RESULTS: Fifty trials met the inclusion criteria, 45 in men after radical prostatectomy, four trials after TURP and one trial after either operation. The trials included 4717 men of whom 2736 had an active conservative intervention. There was considerable variation in the interventions, populations and outcome measures. Data were not available for many of the pre-stated outcomes. Men's symptoms improved over time irrespective of management.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence up to 12 months after radical prostatectomy; the quality of the evidence was judged to be moderate (for example 57% with urinary incontinence in the intervention group versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22). One large multi-centre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrow CIs. It seems unlikely that men benefit from one-to-one PFMT therapy after TURP. Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation, or combinations of treatments might be beneficial but the evidence was limited. Amongst trials of conservative treatment for all men after radical prostatectomy, aimed at both treatment and prevention, there was moderate evidence of an overall benefit from pelvic floor muscle training versus control management in terms of reduction of urinary incontinence (for example 10% with urinary incontinence after one year in the intervention groups versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution because the risk of bias assessment showed methodological limitations. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remained undetermined as no trials involving these interventions were identified.  AUTHORS' CONCLUSIONS: The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. The evidence is conflicting and therefore rigorous, adequately powered randomised controlled trials (RCTs) which abide by the principles and recommendations of the CONSORT statement are still needed to obtain a definitive answer. The trials should be robustly designed to answer specific well constructed research questions and include outcomes which are important from the patient's perspective in decision making and are also relevant to the healthcare professionals. Long-term incontinence may be managed by an external penile clamp, but there are safety problems

Virtual and Augmented Reality in Medical Education

Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models that are currently upgrading medical education. VR provides a 3D and dynamic view of structures and the ability of the user to interact with them. The recent technological advances in haptics, display systems, and motion detection allow the user to have a realistic and interactive experience, enabling VR to be ideal for training in hands-on procedures. Consequently, surgical and other interventional procedures are the main fields of application of VR. AR provides the ability of projecting virtual information and structures over physical objects, thus enhancing or altering the real environment. The integration of AR applications in the understanding of anatomical structures and physiological mechanisms seems to be beneficial. Studies have tried to demonstrate the validity and educational effect of many VR and AR applications, in many different areas, employed via various hardware platforms. Some of them even propose a curriculum that integrates these methods. This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented

Internal Landmarks of the prostate in transrectal ultrasound as basis for long-term monitoring and targeted biopsy: an observational study

To monitor prostatic tissue changes (Trend Monitoring) and perform authentic targeted biopsy, it is essential to reliably identify the same region of interest (ROI) of the prostate and hit targets in their true anatomical locations over time. Transrectal ultrasound (TRUS) identifiable morphologic structures including calcifications, cysts or anatomical fix-points are utilized as natural anchor points (Internal Landmarks) to facilitate exact imaging correlation, and this technique is termed as “Internal Fusion”. This study analyses the feasibility and accuracy of Internal Landmarks. From January 2017 to May 2018, 164 patients with at least one prior series of 5-mm spaced TRUS images analyzed by artificial intelligence algorithm and stored as computed tomographic online data set (AI-US-CT) were included. Operators collected new TRUS images in one-to-one correlation with each prostate cross-section of the previous examinations based on Internal Landmarks and targeted biopsies were taken if with indication. Overall, 1846 Internal Landmarks were utilized as anchor points during Trend Monitoring, including prostatic calcifications (1128, 62%), cysts (524, 28%), seminal colliculus (133, 7%) and others (61, 3%). Basing on re-locating of Internal Landmarks, accurate correlations were attained in 1021 out of 1090 TRUS slices (94%), after years, despite volume changes. The longest Trend Monitoring with exact image correlation had so far reached 9 years and 5 months. Internal Landmarks are of vital importance to exact image correlation in long-term monitoring of the prostate. Trend Monitoring by ANNA/C-TRUS could possibly offer a new opportunity not only in continuous observation of prostatic natural change or disease progression by imaging as a complement to longitudinal PSA, but also to perform per-lesion-based active surveillance or focal therapy. In case of PCa suspicion, Internal Fusion helps targeted biopsies in high accuracy with less biopsy cores

Development of South Australian-Victorian Prostate Cancer Health Outcomes Research Dataset

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.BACKGROUND: Prostate cancer is the most commonly diagnosed and prevalent malignancy reported to Australian cancer registries, with numerous studies from single institutions summarizing patient outcomes at individual hospitals or States. In order to provide an overview of patterns of care of men with prostate cancer across multiple institutions in Australia, a specialized dataset was developed. This dataset, containing amalgamated data from South Australian and Victorian prostate cancer registries, is called the South Australian-Victorian Prostate Cancer Health Outcomes Research Dataset (SA-VIC PCHORD). RESULTS: A total of 13,598 de-identified records of men with prostate cancer diagnosed and consented between 2008 and 2013 in South Australia and Victoria were merged into the SA-VIC PCHORD. SA-VIC PCHORD contains detailed information about socio-demographic, diagnostic and treatment characteristics of patients with prostate cancer in South Australia and Victoria. Data from individual registries are available to researchers and can be accessed under individual data access policies in each State. CONCLUSIONS: The SA-VIC PCHORD will be used for numerous studies summarizing trends in diagnostic characteristics, survival and patterns of care in men with prostate cancer in Victoria and South Australia. It is expected that in the future the SA-VIC PCHORD will become a principal component of the recently developed bi-national Australian and New Zealand Prostate Cancer Outcomes Registry to collect and report patterns of care and standardised patient reported outcome measures of men nation-wide in Australia and New Zealand

Better Medicine

https://scholarlyworks.lvhn.org/better-medicine/1008/thumbnail.jp

A three-layer planning architecture for the autonomous control of rehabilitation therapies based on social robots

This manuscript focuses on the description of a novel cognitive architecture called NAOTherapist, which provides a social robot with enough autonomy to carry out a non-contact upper limb rehabilitation therapy for patients with physical impairments, such as cerebral palsy and obstetric brachial plexus palsy. NAOTherapist comprises three levels of Automated Planning. In the high-level planning, the physician establishes the parameters of the therapy such as the scheduling of the sessions, the therapeutic objectives to be achieved and certain constraints based on the medical records of the patient. This information is used to establish a customized therapy plan. The objective of the medium-level planning is to execute and monitor every previous planned session with the humanoid robot. Finally, the low-level planning involves the execution of path-planning actions by the robot to carry out different low-level instructions such as performing poses. The technical evaluation shows an accurate definition and monitoring of the therapies and sessions and a fluent interaction with the robot. This automated process is expected to save time for the professionals while guaranteeing the medical criteria.This work is partially funded by grant TIN2015-65686-C5-1-R and TIN2012-38079-C03-02 of Spanish Ministerio de Economía y Competitividad

Lower Urinary Tract Dysfunction

Lower urinary tract dysfunction (LUTD) is an umbrella diagnosis that covers the abnormalities of anatomy and function in the bladder, urethra, and, in men, the prostate. People with LUTD face a number of social, mental, and physical health effects due to the symptoms. Despite the increasing evidence in the assessment and management of lower urinary tract symptoms, it remains a challenge to bridge the gap between research evidence and clinical practice. In this book, each and every one of the authors presents a remarkable work for how to apply the evidence to clinical practice from different aspects. I hope this book is a key for every reader to open the door to LUTD

Endoscopic tissue liquidisation of the prostate, bladder and kidney

Endoscopic techniques have revolutionised the practice of all specialities of surgery. Endoscopic access has been either via a natural route, such as the urethra, or percutaneously, as in percutaneous intrarenal stone surgery. Potential endoscopic procedures for bulk tissue removal have been limited by the need to reduce that tissue to a size smaller than the endoscopic channel used. An attempt has been made to create a device that will liquidise and aspirate tissue through an endoscope, This Instrument has been called the Endoscopic Liquidiser and Surgical Aspirator (ELSA). This report details the design and development of the ELSA which has led to its clinical application. The device is 5 mm in diameter and is used through a specially made endoscope of 8.5 mm outer diameter (approximately 27 French). It consists of a high speed rotating blade mounted in a housing that provides irrigation for efficient 1iquidisation and a channel for aspiration of the tissue. Laboratory evaluation was measured by the removal rates of different tissues. The optimum parameters of blade speed, irrigation flow and aspiration were established after a series of controlled experiments. Blade shape was also found to be important and a study of the material strengths of different tissues was required to establish that blade design should vary for each tissue used. Under optimum laboratory conditions fresh human prostate could be removed at 2.4 g/min and renal cortex at 14.6 g/min. The resultant aspirate contained particles ranging from 10 microns to 3 mm, but the majority were less than 200 microns. Flow cytometry was required as the only reasonable method of rapid pathological diagnosis. The action of the ELSA did not confer any Inherent haemostatic benefit and a diathermy plate was added to the tip of the instrument. The ELSA was successfully used to remove benign prostatic tissue from 7 patients with bladder outflow obstruction. However the procedures were slow and visualisation was poor once the liquidisation began. The mean operating time was 85 minutes (range 50 - 120). 1 patient suffered a fatal capsular perforation, but otherwise morbidity v/as not dissimilar from a control group undergoing a standard transurethral diathermy resection. 6'7 patients regained an improved stream with good control. The ELSA was used in the same transurethral method for the removal of superficial bladder tumours in 10 patients. The same problem of impaired vision was found, but the removal was very rapid as one would expect with a soft non-fibro\is material. The postoperative morbidity was greater than in a control group using a diathermy resectoscope due to bladder perforation with the ELSA in 1 case. A percutaneous endoscopic nephrectomy has been achieved in 2 dogs. Each kidney was embolised with "Ethibloc" (a material that completely occupies all arterial capillary beds), An Intrarenal approach was compared with an extrarenal, retroperitoneal one; the latter using carbon dioxide insufflation. Both procedures were successful. Haeraostasis was not a problem. These may be suitable clinical techniques for the minimally invasive removal of infected kidneys prior to transplantation. The presence of stones would not be a problem because of the ability of the ELSA to fragment and aspirate stone particles as efficently as any ultrasound device. This was confirmed in a series of laboratory tests on various stone types and in 5 patients with urinary stones. An extension of the concept of minimally invasive bulk tissue aspiration is the integration of robotics into this form of surgery. The ELSA has been attached to an industrial robot. The mechanism of a transurethral prostatectomy has been studied in order to program the robot. A robotic prostatectomy in a simulation model has been performed. Each procedure can be preprogrammed according to the dimensions of the gland. The in vitro study confirmed that the robot was consistent and therefore safe; and rapid (mean removal time 5 rains) because visualisation was not required for orientation. In conclusion, the ELSA has proved to be ati efficient instrument for endoscopic tissue removal but its clinical superiority is only for less fibrous tissues and improved visualisation will be required. It still requires ancillary methods for haemostasis and the use of a capillary embolisation technique in the kidney may have applications elsewhere. The robotic study was not just an academic exercise. Robotics will be a feature of future surgery

Prostate-Associated Gene 4 (PAGE4): Leveraging the Conformational Dynamics of a Dancing Protein Cloud as a Therapeutic Target.

Prostate cancer (PCa) is a leading cause of mortality and morbidity globally. While genomic alterations have been identified in PCa, in contrast to some other cancers, use of such information to personalize treatment is still in its infancy. Here, we discuss how PAGE4, a protein which appears to act both as an oncogenic factor as well as a metastasis suppressor, is a novel therapeutic target for PCa. Inhibiting PAGE4 may be a viable strategy for low-risk PCa where it is highly upregulated. Conversely, PAGE4 expression is downregulated in metastatic PCa and, therefore, reinstituting its sustained expression may be a promising option to subvert or attenuate androgen-resistant PCa. Thus, fine-tuning the levels of PAGE4 may represent a novel approach for personalized medicine in PCa

Abstracts of the College of Surgeons of East, Central and Southern Africa (COSECSA) 19th Annual General Meeting and International Scientific Conference

Conference Abstract