Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility

Despite advances in the field of male reproductive health, idiopathic male infertility, in which a man has altered semen characteristics without an identifiable cause and there is no female factor infertility, remains a challenging condition to diagnose and manage. Increasing evidence suggests that oxidative stress (OS) plays an independent role in the etiology of male infertility, with 30% to 80% of infertile men having elevated seminal reactive oxygen species levels. OS can negatively affect fertility via a number of pathways, including interference with capacitation and possible damage to sperm membrane and DNA, which may impair the sperm’s potential to fertilize an egg and develop into a healthy embryo. Adequate evaluation of male reproductive potential should therefore include an assessment of sperm OS. We propose the term Male Oxidative Stress Infertility, or MOSI, as a novel descriptor for infertile men with abnormal semen characteristics and OS, including many patients who were previously classified as having idiopathic male infertility. Oxidation-reduction potential (ORP) can be a useful clinical biomarker for the classification of MOSI, as it takes into account the levels of both oxidants and reductants (antioxidants). Current treatment protocols for OS, including the use of antioxidants, are not evidence-based and have the potential for complications and increased healthcare-related expenditures. Utilizing an easy, reproducible, and cost-effective test to measure ORP may provide a more targeted, reliable approach for administering antioxidant therapy while minimizing the risk of antioxidant overdose. With the increasing awareness and understanding of MOSI as a distinct male infertility diagnosis, future research endeavors can facilitate the development of evidence-based treatments that target its underlying cause

Launching a successful robotic program

In spite of the substantial benefits of robotic surgery (RS) over standard laparoscopy, performing robotic surgery still requires for the surgeon to undergo a necessary learning curve (LC), in order to ensure the safe introduction of this technology. In this setting the adoption of RS at any institution requires the establishment of a well-structured plan and certain key elements to be in place to ensure successful implementation of a robotics program. A thorough initial design and implementation lead to the execution of clinical services, which meet previously established goals. Once the execution phase is established, the next step is to focus on maintenance and growth to maximize the benefits of the program We portray the necessary phases for creating a successful robotic program, paying special attention to the aspects that allowed our facility to create a profitable robotic-assisted laparoscopic prostatectomy program The true success and durability of RS will depend on long-term outcomes. For individual programs, a thorough infrastructure is necessary to approachoverall profitability and efficiency. Initial planning is dependent on a risk/benefit analysis, economic model, and lead surgeon. Realistic early expectations often require a substantial initial investment An OR team, hospital administration support, possible OR modification, and continued marketing become the next agenda. Each focus area should be established prior to the launch of the program. Finally, it is important to frequently review the goals of the program in the initial phase because early identification of problem areas, possible changes to improve efficiency or outcomes, and justification for the risk/cost of a program can all be obtained and handled ahead of tim

Modified Technique Of Robotic-Assisted Simple Prostatectomy: Advantages Of A Vesico-Urethral Anastomosis

OBJECTIVES To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique. METHODS We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical \u27trigonization\u27 of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall. RESULTS The patients\u27 average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP. CONCLUSIONS Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP. © 2011 BJU International

Retropubic, Laparoscopic, And Robot-Assisted Radical Prostatectomy: A Critical Review Of Outcomes Reported By High-Volume Centers

Purpose: To critically review perioperative outcomes, positive surgical margin (PSM) rates, and functional outcomes of several large series of retropubic radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted radical prostatectomy (RARP) currently available in the literature. Methods: A Medline database search was performed from November 1994 to May 2009, using medical subject heading search terms prostatectomy and Outcome Assessment (Health Care) and text words retropubic, robotic, and laparoscopic. Only studies with a sample size of 250 or more patients were considered. Weighted means were calculated for all outcomes using the number of patients included in each study as the weighing factor. Results: We identified 30 articles for RRP, 14 for LRP, and 14 for RARP. The mean intraoperative and postoperative RRP transfusion rates for RRP, LRP, and RARP were 20.1%, 3.5%, and 1.4%, respectively. The weighted mean postoperative complication rates for RRP, LRP, and RARP were 10.3% (4.8% to 26.9%), 10.98% (8.9 to 27.7%), and 10.3% (4.3% to 15.7%), respectively. RARP revealed a mean overall PSM rate of 13.6%, whereas LRP and RRP yielded a PSM of 21.3% and 24%, respectively. The weighted mean continence rates at 12 month follow-up for RRP, LRP, and RARP were 79%, 84.8%, and 92%, respectively. The weighted mean potency rates for patients who underwent unilateral or bilateral nerve sparing, at 12 month follow-up, were 43.1% and 60.6% for RRP, 31.1% and 54% for LRP, and 59.9% and 93.5% for RARP. Conclusion: RRP, LRP, and RARP performed in high-volume centers are safe options for treatment of patients with localized prostate cancer, presenting similar overall complication rates. LRP and RARP, however, are associated with decreased operative blood loss and decreased risk of transfusion when compared with RRP. Our analysis including high-volume centers also showed lower weighted mean PSM rates and higher continence and potency rates after RARP compared with RRP and LRP. However, the lack of randomized trials precludes definitive conclusions. Copyright © 2010, Mary Ann Liebert, Inc

Corrigendum Re: “Influence Of Modified Posterior Reconstruction Of The Rhabdosphincter On Early Recovery Of Continence And Anastomotic Leakage Rates After Robot-Assisted Radical Prostatectomy” [Eur Urol 2011;59:72–80](S0302283810007566)(10.1016/J.Eururo.2010.08.025)

A typographical error has been identified in the Abstract whereby results for the continence rate at 1, 4, 12, and 24 wk postoperatively were incorrectly transposed for the posterior reconstruction (PR) and non-PR groups. The correct rates are given in Table 4 in the article. The relevant sentences in the Results and limitations section of the Abstract should therefore read as follows: In the PR group, the continence rates at 1, 4, 12, and 24 wk postoperatively were 28.7%, 51.6%, 91.1%, and 97%, respectively; in the non-PR group, the continence rates were 22.7%, 42.7%, 91.8%, and 96.3%, respectively. The modified PR technique resulted in significantly higher continence rates at 1 and 4 wk after catheter removal (p = 0.048 and 0.016, respectively), although the continence rates at 12 and 24 wk were not significantly affected (p = 0.908 and p = 0.741, respectively)

Does The Presence Of Median Lobe Affect Outcomes Of Robot-Assisted Laparoscopic Radical Prostatectomy?

This study presents an integrated k-means clustering and gravity model (IKCGM) for investigating the spatiotemporal patterns of nutrient and associated dissolved oxygen levels in Tampa Bay, Florida. By using a k-means clustering analysis to first partition the nutrient data into a user-specified number of subsets, it is possible to discover the spatiotemporal patterns of nutrient distribution in the bay and capture the inherent linkages of hydrodynamic and biogeochemical features. Such patterns may then be combined with a gravity model to link the nutrient source contribution from each coastal watershed to the generated clusters in the bay to aid in the source proportion analysis for environmental management. The clustering analysis was carried out based on 1 year (2008) water quality data composed of 55 sample stations throughout Tampa Bay collected by the Environmental Protection Commission of Hillsborough County. In addition, hydrological and river water quality data of the same year were acquired from the United States Geological Survey\u27s National Water Information System to support the gravity modeling analysis. The results show that the k-means model with 8 clusters is the optimal choice, in which cluster 2 at Lower Tampa Bay had the minimum values of total nitrogen (TN) concentrations, chlorophyll a (Chl-a) concentrations, and ocean color values in every season as well as the minimum concentration of total phosphorus (TP) in three consecutive seasons in 2008. The datasets indicate that Lower Tampa Bay is an area with limited nutrient input throughout the year. Cluster 5, located in Middle Tampa Bay, displayed elevated TN concentrations, ocean color values, and Chl-a concentrations, suggesting that high values of colored dissolved organic matter are linked with some nutrient sources. The data presented by the gravity modeling analysis indicate that the Alafia River Basin is the major contributor of nutrients in terms of both TP and TN values in all seasons. With this new integration, improvements for environmental monitoring and assessment were achieved to advance our understanding of sea-land interactions and nutrient cycling in a critical coastal bay, the Gulf of Mexico. © 2012 The Royal Society of Chemistry

Predictive Factors For Positive Surgical Margins And Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy

Background: Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). Objective: We sought to identify predictive factors for PSMs and their locations after RARP. Design, setting, and participants: We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. Intervention: All patients underwent RARP performed by a single surgeon with previous experience of \u3e1500 cases. Measurements: Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. Results and limitations: In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p \u3c 0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p = 0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0-1.3; p = 0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. Conclusions: Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs. © 2010 European Association of Urology

Continence, Potency And Oncological Outcomes After Robotic-Assisted Radical Prostatectomy: Early Trifecta Results Of A High-Volume Surgeon

OBJECTIVE • To evaluate early trifecta outcomes after robotic-assisted radical prostatectomy (RARP) performed by a high-volume surgeon. PATIENTS AND METHODS • We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. • Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. • Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse \u3e50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of \u3e0.2 ngmL after RARP. • Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56-65 years and Group 3, \u3e65 years. RESULTS • The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. • There were no statistically significant differences in the continence and BCR-free rates between the three age groups at all postoperative intervals analysed. • Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P \u3c 0.01 at all time points). • Similarly, younger men also had a shorter time to achieving the trifecta and had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P \u3c 0.01 at all time points). CONCLUSION • RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. • Younger men had a shorter time to achieving the trifecta and higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP. © 2010 BJU INTERNATIONAL