Approach to endoscopic extraperitoneal radical prostatectomy (EERPE): the impact of previous laparoscopic experience on the learning curve

BACKGROUND: We report our approach regarding the technique of endoscopic extraperitoneal radical prostatectomy (EERPE) and analyze the learning curve of two surgeons after thorough technical training under expert monitoring. The purpose of this study was to investigate the influence of expert monitoring on the surgical outcome and whether previous laparoscopic experience influences the surgeon's learning curve. METHODS: EERPE was performed on 120 consecutive patients by two surgeons with different experience in laparoscopy. An analysis and comparison of their learning curve was made. RESULTS: Median operation time: 200 (110-415) minutes. Complications: no conversion, blood transfusion (1.7%), rectal injury (3.3%). Median catheterisation time: 6 (5-45) days. Histopathological data: 55% pT2, 45% pT3 with a positive surgical margin rate of 6.1% and 46%, respectively. After 12 months, 78% of the patients were continent, 22% used 1 or more pad. Potency rate with or without PDE-5-inhibitors was 66% with bilateral and 31% with unilateral nerve-sparing, respectively. Operation time was the only parameter to differ significantly between the two surgeons. CONCLUSION: EERPE can be learned within a short teaching phase. Previous laparoscopic experience is reflected by shorter operation times, not by lower complication rates or superior early oncological data

Stresses in Ytterbium Silicate Multilayer Environmental Barrier Coatings

The internal stresses of plasma-sprayed multilayer ytterbium disilicate environmental barrier coatings were measured using microfocused high-energy X-rays in a transmission geometry. Stresses were measured for as-sprayed and ex-situ heat-treated ytterbium disilicate topcoats at room temperature and during in-situ heating and cooling experiments. In-situ loading experiments were also performed on the topcoat in order to establish its elastic constants. The ytterbium disilicate was found to have a relatively low coefficient of thermal expansion resulting in compressive stresses of approximately 100 MPa throughout the topcoat. In-situ heating experiments revealed a statistically significant stress relaxation in the ytterbium disilicate topcoat upon thermal cycling to temperatures above 1300°C, indicating the onset of stress relaxation but no cracks were observed in SEM micrographs. The stress states were also modeled using a numerical solution; measured stresses were found to be very close to the predicted stresses in ytterbium dilisicate topcoats, while the experimentally determined stresses in the intermediate layers were of much smaller magnitude than the calculated stresses

Belief Revision in Structured Probabilistic Argumentation

In real-world applications, knowledge bases consisting of all the information at hand for a specific domain, along with the current state of affairs, are bound to contain contradictory data coming from different sources, as well as data with varying degrees of uncertainty attached. Likewise, an important aspect of the effort associated with maintaining knowledge bases is deciding what information is no longer useful; pieces of information (such as intelligence reports) may be outdated, may come from sources that have recently been discovered to be of low quality, or abundant evidence may be available that contradicts them. In this paper, we propose a probabilistic structured argumentation framework that arises from the extension of Presumptive Defeasible Logic Programming (PreDeLP) with probabilistic models, and argue that this formalism is capable of addressing the basic issues of handling contradictory and uncertain data. Then, to address the last issue, we focus on the study of non-prioritized belief revision operations over probabilistic PreDeLP programs. We propose a set of rationality postulates -- based on well-known ones developed for classical knowledge bases -- that characterize how such operations should behave, and study a class of operators along with theoretical relationships with the proposed postulates, including a representation theorem stating the equivalence between this class and the class of operators characterized by the postulates

Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature

CONTEXT: Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery. OBJECTIVE: To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology. EVIDENCE ACQUISITION: A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology. EVIDENCE SYNTHESIS: In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES. CONCLUSIONS: NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery

Retropubic, laparoscopic and mini-laparoscopic radical prostatectomy : a prospective assessment of patient scar satisfaction

Published online: 26 October 2014PURPOSE: To compare patient scar satisfaction after retropubic, standard laparoscopic, mini-laparoscopic (ML) and open radical prostatectomy (RP). METHODS: Patients undergoing RP for a diagnosis of localized prostate cancer at a single academic hospital between September 2012 and December 2013 were enrolled in this prospective nonrandomized study. The patients were included in three study arms: open surgery, VLP and ML. A skin stapler was used for surgical wound closure in all cases. Demographic and main surgical outcomes, including perioperative complications, were analyzed. Surgical scar satisfaction was measured using the Patient and Observer Scar Assessment Questionnaire (POSAS) and the two Body Image Questionnaire (BIQ) scales, respectively, recorded at skin clips removal and either at 6 months after surgery. RESULTS: Overall, 32 patients were enrolled and completed the 6 month of follow-up. At clips removal, laparoscopic approaches offered better scar result than open surgery according to the POSAS. However, at 6 months, no differences were detected between VLP and open, whereas ML was still associated with a better scar outcome (p = 0.001). This finding was also confirmed by both BIQ scales, including the body image score (ML 9.8 ± 1.69, open 15.73 ± 3.47, VLP 13.27 ± 3.64; p = 0.001) and the cosmetic score (ML 16.6 ± 4.12, open 10 ± 1.9, LP 12.91 ± 3.59; p = 0.001). Small sample size and lack of randomization represent the main limitations of this study. CONCLUSIONS: ML RP offers a better cosmetic outcome when compared to both open and standard laparoscopic RP, representing a step toward minimal surgical scar. The impact of scar outcome on RP patients' quality of life remains to be determined

To defer or not to defer? A German longitudinal multicentric assessment of clinical practice in urology during the COVID-19 pandemic

Introduction After the outbreak of COVID-19 unprecedented changes in the healthcare systems worldwide were necessary resulting in a reduction of urological capacities with postponements of consultations and surgeries. Material and methods An email was sent to 66 urological hospitals with focus on robotic surgery (RS) including a link to a questionnaire (e.g. bed/staff capacity, surgical caseload, protection measures during RS) that covered three time points: a representative baseline week prior to COVID-19, the week of March 16th-22nd and April 20th-26th 2020. The results were evaluated using descriptive analyses. Results 27 out of 66 questionnaires were analyzed (response rate: 41%). We found a decrease of 11% in hospital beds and 25% in OR capacity with equal reductions for endourological, open and robotic procedures. Primary surgical treatment of urolithiasis and benign prostate syndrome (BPS) but also of testicular and penile cancer dropped by at least 50% while the decrease of surgeries for prostate, renal and urothelial cancer (TUR-B and cystectomies) ranged from 15 to 37%. The use of personal protection equipment (PPE), screening of staff and patients and protection during RS was unevenly distributed in the different centers\u2013however, the number of COVID-19 patients and urologists did not reach double digits. Conclusion The German urological landscape has changed since the outbreak of COVID-19 with a significant shift of high priority surgeries but also continuation of elective surgical treatments. While screening and staff protection is employed heterogeneously, the number of infected German urologists stays low

ATP Enhances Spontaneous Calcium Activity in Cultured Suburothelial Myofibroblasts of the Human Bladder

BACKGROUND: Suburothelial myofibroblasts (sMF) are located underneath the urothelium in close proximity to afferent nerves. They express purinergic receptors and show calcium transients in response to ATP. Therefore they are supposed to be involved in afferent signaling of the bladder fullness. Since ATP concentration is likely to be very low during the initial filling phase, we hypothesized that sMF Ca(2+) activity is affected even at very low ATP concentrations. We investigated ATP induced modulation of spontaneous activity, intracellular calcium response and purinergic signaling in cultured sMF. METHODOLOGY/PRINCIPAL FINDINGS: Myofibroblast cultures, established from cystectomies, were challenged by exogenous ATP in presence or absence of purinergic antagonist. Fura-2 calcium imaging was used to monitor ATP (10(-16) to 10(-4) mol/l) induced alterations of calcium activity. Purinergic receptors (P2X1, P2X2, P2X3) were analysed by confocal immunofluorescence. We found spontaneous calcium activity in 55.18% ± 1.65 of the sMF (N = 48 experiments). ATP significantly increased calcium activity even at 10(-16) mol/l. The calcium transients were partially attenuated by subtype selective antagonist (TNP-ATP, 1 µM; A-317491, 1 µM), and were mimicked by the P2X1, P2X3 selective agonist α,β-methylene ATP. The expression of purinergic receptor subtypes in sMF was confirmed by immunofluorescence. CONCLUSIONS/SIGNIFICANCE: Our experiments demonstrate for the first time that ATP can modulate spontaneous activity and induce intracellular Ca(2+) response in cultured sMF at very low concentrations, most likely involving P2X receptors. These findings support the notion that sMF are able to register bladder fullness very sensitively, which predestines them for the modulation of the afferent bladder signaling in normal and pathological conditions

Frequent new particle formation over the high Arctic pack ice by enhanced iodine emissions

In the central Arctic Ocean the formation of clouds and their properties are sensitive to the availability of cloud condensation nuclei (CCN). The vapors responsible for new particle formation (NPF), potentially leading to CCN, have remained unidentified since the first aerosol measurements in 1991. Here, we report that all the observed NPF events from the Arctic Ocean 2018 expedition are driven by iodic acid with little contribution from sulfuric acid. Iodic acid largely explains the growth of ultrafine particles (UFP) in most events. The iodic acid concentration increases significantly from summer towards autumn, possibly linked to the ocean freeze-up and a seasonal rise in ozone. This leads to a one order of magnitude higher UFP concentration in autumn. Measurements of cloud residuals suggest that particles smaller than 30 nm in diameter can activate as CCN. Therefore, iodine NPF has the potential to influence cloud properties over the Arctic Ocean