Different Nerve-Sparing Techniques during Radical Prostatectomy and Their Impact on Functional Outcomes

The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords “nerve-sparing”, “techniques”, “prostatectomy” and “outcomes”. Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary

Comments on the Extraperitoneal Approach for Standard Laparoscopic Radical Prostatectomy: What Is Gained and What Is Lost

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients

Predicting human intention in visual observations of hand/object interactions

Abstract—The main contribution of this paper is a prob-abilistic method for predicting human manipulation intention from image sequences of human-object interaction. Predicting intention amounts to inferring the imminent manipulation task when human hand is observed to have stably grasped the object. Inference is performed by means of a probabilistic graphical model that encodes object grasping tasks over the 3D state of the observed scene. The 3D state is extracted from RGB-D image sequences by a novel vision-based, markerless hand-object 3D tracking framework. To deal with the high-dimensional state-space and mixed data types (discrete and continuous) involved in grasping tasks, we introduce a generative vector quantization method using mixture models and self-organizing maps. This yields a compact model for encoding of grasping actions, able of handling uncertain and partial sensory data. Experimentation showed that the model trained on simulated data can provide a potent basis for accurate goal-inference with partial and noisy observations of actual real-world demonstrations. We also show a grasp selection process, guided by the inferred human intention, to illustrate the use of the system for goal-directed grasp imitation. I

Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy:A systematic review and meta-analysis

Objectives: To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP). Methods: The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be â¥6 months. Results: In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of â0.30 days (95% confidence interval [CI] â0.35, â0.24) for the laparoscopic group and 1.09 days (95% CI â1.47, â0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01). Conclusion: This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate. Keywords: Extraperitoneal, Laparoscopy, Minimally invasive, Robotic, Transperitoneal, Prostatectom

H-GAN: the power of GANs in your Hands

We present HandGAN (H-GAN), a cycle-consistent adversarial learning approach implementing multi-scale perceptual discriminators. It is designed to translate synthetic images of hands to the real domain. Synthetic hands provide complete ground-truth annotations, yet they are not representative of the target distribution of real-world data. We strive to provide the perfect blend of a realistic hand appearance with synthetic annotations. Relying on image-to-image translation, we improve the appearance of synthetic hands to approximate the statistical distribution underlying a collection of real images of hands. H-GAN tackles not only the cross-domain tone mapping but also structural differences in localized areas such as shading discontinuities. Results are evaluated on a qualitative and quantitative basis improving previous works. Furthermore, we relied on the hand classification task to claim our generated hands are statistically similar to the real domain of hand.Spanish Government PID2019-104818RB-I00 grant for the MoDeaAS project, supported with Feder funds. This work has also been supported by two Spanish national grants for PhD studies, FPU17/00166, and ACIF/2018/197 respectively

Management of Urinary Retention in Patients with Benign Prostatic Obstruction : A Systematic Review and Meta-analysis

Context: Practice patterns for the management of urinary retention (UR) secondary to benign prostatic obstruction (BPO; UR/BPO) vary widely and remain unstandardized. Objective: To review the evidence for managing patients with UR/BPO with pharmacological and nonpharmacological treatments included in the European Association of Urology guidelines on non-neurogenic male lower urinary tract symptoms. Evidence acquisition: Search was conducted up to April 22, 2018, using CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. This systematic review included randomized controlled trials (RCTs) and prospective comparative studies. Methods as detailed in the Cochrane handbook were followed. Certainty of evidence (CoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Evidence synthesis: Literature search identified 2074 citations. Twenty-one studies were included (qualitative synthesis). The evidence for managing patients with UR/BPO with pharmacological or nonpharmacological treatments is limited. CoE for most outcomes was low/very low. Only alpha 1-blockers (alfuzosin and tamsulosin) have been evaluated in more than one RCT. Pooled results indicated that a1-blockers provided significantly higher rates of successful trial without catheter compared with placebo [alfuzosin: 322/540 (60%) vs 156/400 (39%) (odds ratio {OR} 2.28, 95% confidence interval {CI} 1.55 to 3.36; participants = 940; studies = 7; I-2 = 41%; low CoE); tamsulosin: 75/158 (47%) vs 40/139 (29%) (OR 2.40, 95% CI 1.29 to 4.45; participants = 297; studies = 3; I-2 = 30%; low CoE)] with rare adverse events. Similar rates were achieved with tamsulosin or alfuzosin [51/87 (59%) vs 45/84 (54%) (OR 1.28, 95% CI 0.68 to 2.41;participants = 171; studies = 2; I-2 = 0%; very low CoE)]. Nonpharmacological treatments have been evaluated in RCTs/prospective comparative studies only sporadically. Conclusions: There is some evidence that usage of alpha 1-blockers (alfuzosin and tamsulosin) may improve resolution of UR/BPO. As most nonpharmacological treatments have not been evaluated in patients with UR/BPO, the evidence is inconclusive about their benefits and harms. Patient summary: There is some evidence that alfuzosin and tamsulosin may increase the rates of successful trial without catheter, but little or no evidence on various nonpharmacological treatment options for managing patients with urinary retention secondary to benign prostatic obstruction. (c) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.Peer reviewe

Investigation of renoprotective properties of pharmacological substances in an experimental model of reperfusion injury in rats

Aim of the study: Despite the wide progress in the understanding of the pathophysiological mechanisms underlining ischemia reperfusion injury of the kidney, currently there is lack of available pharmacological substances against the phenomenon for use in the clinical setting. In this study we investigate the ability of vardenafil, a widely used phosphodiesterase 5 (PDE5) inhibitor, to attenuate ischemia reperfusion injury in a experimental model in rats. Materials and methods: In total, 71 Wistar rats were divided into 7 groups including a sham group, a control group, 4 vardenafil treated groups, in which 0.02, 0.2, 2 and 20 μg/kg of substance was administered IV one hour before ischemia and a group in which 2 μg/kg of vardenafil was administered IV upon initiation of reperfusion. Animals were subjected to left nephrectomy and right kidney ischemia for 45 minutes via clamping of renal pedicle. After 4 hours of reperfusion animals were either sacrificed and blood and urine sampling as well as their kidneys were retrieved for analysis or they were subjected to renal scintigraphy. Evaluated parameters were serum creatinine, fractional excretion of Na (FENa), renal histology, scintigrphic perfusion, cGMP, ERK and pERK tissue levels. Results: Administration of vardenafil before ischemia resulted in reduction of plasma creatinine and FENa levels, ameliorated histological deterioration in ischemic kidneys and improved scintigraphic renal perfusion. In the highest tested dose of 20 μg/kg biochemical and histological assessment of renal function and morphology of ischemic kidneys did not differ statistically from sham group in which animals did not undergo ischemia. The underlying mechanism of cytoprotection involves elevation of cGMP levels and ERK phosphorylation. Administration of vardenafil after ischemia did not demonstrated any renal protection Conclusions: A wealth of data, part of which are enclosed in current thesis, demonstrate significant renoprotective properties for PDE5 inhibitors against renal ischemia reperfusion injury in the experimental setting. Adding the excellent safety profile of such drugs, their use against renal ischemia reperfusion injury is humans is regarded as very attractive and promising.Σκοπός της μελέτης: Μολονότι τα τελευταία χρόνια έχει επιτελεστεί σημαντική πρόοδος στην κατανόηση του παθοφυσιολογικού μηχανισμού πίσω από το φαινόμενο της βλάβης εξ ισχαιμίας και επαναιμάτωσης στο νεφρό, υπάρχει έλλειψη φαρμακευτικών παραγόντων στην κλινική πράξη που να μπορούν να την ανατρέψουν. Στην παρούσα μελέτη ερευνάται η επίδραση της βαρδεναφίλης, ενός ευρέως διαδεδομένου αναστολέα της φωσφοδιεστεράσης 5 (PDE5) σε ένα πειραματικό μοντέλο ισχαιμίας-επαναιμάτωσης στον αρουραίο. Υλικά και μέθοδος: Στο σύνολο 71 αρουραίοι ράτσας Wistar διαχωρίστηκαν σε 7 ομάδες συμπεριλαμβανομένης μιας ομάδας μάρτυρα, μιας ομάδας ελέγχου, 4 ομάδων χορήγησης βαρδεναφίλης σε δόσεις 0.02, 0.2, 2 και 20 μg/kg μία ώρα πριν την ισχαιμία και μία ομάδα χορήγησης 2 μg/kg βαρδεναφιλης αμέσως μετά την ισχαιμία. Τα πειραματόζωα υποβλήθηκαν σε αριστερή νεφρεκτομή και το δεξιό νεφρό υποβλήθηκε σε 45 λεπτά ισχαιμίας με διακοπή της παροχής αίματος στο επίπεδο του νεφρικού μίσχου. Τέσσερις ώρες μετά το τέλος της ισχαιμίας τα πειραματόζωα θανατώθηκαν για λήψη των νεφρών τους, αίματος και ούρων ή υποβλήθηκαν σε σπινθηρογράφημα νεφρού. Οι εκτιμώμενες παράμετροι ήταν τα επίπεδα κρεατινίνης πλάσματος, το κλάσμα FENa, η ιστολογική ανάλυση του νεφρού, η καθήλωση ραδιοφαρμάκου, τα επίπεδα cGMP, ERK και pERK στο νεφρό. Αποτελέσματα: Η προισχαιμική χορήγηση βαρδεναφίλης είχε ως αποτέλεσμα την μείωση των επιπέδων κρεατινίνης πλάσματος και του λόγου FENa, στην απεμπόληση των ισχαιμικών ιστολογικών βλαβών του νεφρού και στην βελτίωση της σπινθηρογραφικής καθήλωσης του ραδιοφαρμάκου. Στη μέγιστη χορηγούμενη δόση των 20 μg/kg οι βιοχημικές και ιστολογικές παράμετροι δεν διέφεραν στατιστικά από την ομάδα μάρτυρα που δεν υποβλήθηκε σε ισχαιμία. Ο μηχανισμός κυτταροπροστασίας περιλαμβάνει την αύξηση των επιπέδων του cGMP και τη φωσφορυλίωση των κινασών ERK. Η χορήγηση βαρδεναφίλης κατά την επαναιμάτωση δεν προσέφερε νεφροπροστασία. Συμπεράσματα: Συσσωρευμένη βιβλιογραφία, μέρος της οποίας είναι και η παρούσα μελέτη, αναδεικνύει σημαντική νεφροπροστασία από τους αναστολείς της PDE5 σε πειραματικά μοντέλα νεφρικής ισχαιμίας και επαναιμάτωσης. Σε συνδυασμό με το εξαιρετικό τους προφίλ ασφάλειας, οι αναστολείς της PDE5 καθίστανται ελκυστικοί προς χρήση ενάντια στην ισχαιμία και επαναιμάτωση του νεφρού στον άνθρωπο