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Summary: Background: The extent of arterial disease in patients with erectile dysfunction (ED) non-responsive to intracavernosal injection of Alprostadil is of importance for therapeutic options. However, published evidence, in particular angiographically validated is scarce. Here we investigated arterial lesion patterns in this specific patient cohort by selective angiography. Patients and methods: A cohort of 239 patients received a clinical and duplex-sonographic workup for ED of suspected vascular origin. Duplex ultrasound of the cavernosal arteries was performed after intracavernosal injection of 10 μg Alprostadil. Consequently, standardized workup included grading of the erectile and determination of peak systolic velocity (PSV) and end-diastolic velocity (EDV) in both cavernosal arteries. PSV-values below 30 cm/sec indicated reduced arterial flow, whereas EDV-values above 15 cm/sec indicated a venous leak of the pudendal veins. All patients with suspected arterial ED based on duplex sonography underwent contrast-enhanced computed tomography. Endovascular therapy was carried out in ED patients not responsive or with significant side effects to PDE-5-inhibitors or Alprostadil by selective angiographic depiction of erection-related arteries. Results: 54 patients with a mean age of 61.2 (±9.8) years underwent angioplasty of erectionr elated arteries. Out of these 48/54 (89%) patients presented with an erection considered insufficient for penetration (E0-E3) subsequent to intracavernous application of 10 μg Alprostadil. 14/48 (29%) patients had bilateral arterial obstructions and 34/48 (71%) had unilateral disease. Commonly affected was the internal pudendal artery (n = 31, 65%), followed closely by the common penile artery (n = 30, 64%). The least affected arteries were the dorsal penile (n = 6, 13%), hypogastric (n = 4, 8%), common iliac (n = 4, 8%), cavernosal (n = 4, 8%), and inferior gluteal (n = 1, 2%) arteries. Conclusions: Arterial obstructions amenable to endovascular revascularization are frequent in patients non-responsive to intracavernosal prostaglandin administration. Therapeutic strategies in ED patients non-responsive to conservative measures should therefore consider endovascular treatment opportunities.

Purpose Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery. Patients and Methods Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls. Results From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72-98%), kurtosis 1.60 and skewness -1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) - 11, r(279)=0.33, p

Background The evidence base for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is nascent. We sought to characterize SARS-CoV-2 transmission within US households and estimate the household secondary infection rate (SIR) to inform strategies to reduce transmission. Methods We recruited patients with laboratory-confirmed SARS-CoV-2 infection and their household contacts in Utah and Wisconsin during 22 March 2020–25 April 2020. We interviewed patients and all household contacts to obtain demographics and medical histories. At the initial household visit, 14 days later, and when a household contact became newly symptomatic, we collected respiratory swabs from patients and household contacts for testing by SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) and sera for SARS-CoV-2 antibodies testing by enzyme-linked immunosorbent assay (ELISA). We estimated SIR and odds ratios (ORs) to assess risk factors for secondary infection, defined by a positive rRT-PCR or ELISA test. Results Thirty-two (55%) of 58 households secondary infection among household contacts. The SIR was 29% (n = 55/188; 95% confidence interval [CI], 23%–36%) overall, 42% among children (aged Conclusions We found substantial evidence of secondary infections among household contacts. People with COVID-19, particularly those with immunocompromising conditions or those with household contacts with diabetes, should take care to promptly self-isolate to prevent household transmission.

Background During 2017, in response to a physician’s report, the Wisconsin Department of Health Services, Division of Public Health, began investigating an outbreak of febrile illness among attendees of a retreat where never frozen, intentionally undercooked, locally harvested venison was served. Preliminary testing tentatively identified the illness as toxoplasmosis. Methods Confirmatory human serology panels and testing of the venison to confirm and categorize the presence and type of Toxoplasma gondii were completed by French and American national reference laboratories. All 12 retreat attendees were interviewed; medical records were reviewed. Results All attendees were male; median age was 51 years (range: 22–75). After a median incubation period of 7 days, 9 (82%) of 11 exposed persons experienced illness lasting a median of 12 days. All 9 sought outpatient healthcare for symptoms including fever, chills, sweats, and headache (100%) and ocular disturbances (33%). Testing confirmed the illness as toxoplasmosis and venison as the infection source. Multiple laboratory results were atypical for toxoplasmosis, including transaminitis (86%), lymphocytopenia (88%), thrombocytopenia (38%), and leukopenia (63%). One exposed but asymptomatic person was seronegative; the other had immunity from prior infection. The T. gondii strain was identified as closely related to an atypical genotype (haplogroup 12, polymerase chain reaction restriction fragment length polymorphism genotype 5) common in North American wildlife but with previously uncharacterized human clinical manifestations. Conclusions The T. gondii strain contaminating the venison might explain the unusual clinical presentations. In North America, clinicians and venison consumers should be aware of risk for severe or unusual presentations of acute toxoplasmosis after consuming undercooked game meat.

Background To facilitate evidence-based medicine (EBM) on an individual level, it may be important for clinical practice guidelines (CPGs) to incorporate the performance parameters of diagnostic studies and therapeutic interventions (such as likelihood ratio and absolute benefit or harm), and to incorporate relevant patient contexts that may influence decision-making. We sought to determine the extent to which heart failure CPGs currently incorporate this information. Methods We reviewed the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2013 Heart Failure CPG, the 2017 ACCF/AHA/HFSA update, and European Society of Cardiology (ESC) 2016 Heart Failure CPG. We abstracted variables for each CPG recommendation from the following domains: quality of evidence, strength of recommendation, diagnostic and therapeutic performance parameters, and patient context. Results We examined 169 recommendations from the ACCF/AHA 2013 CPGs and 2017 update and 187 recommendations from the 2016 ESC CPGs. Performance parameters for diagnostic studies (2013 ACCF/AHA: 13%; 2017 ACCF/AHA/HFSA update: 0%; 2016 ESC: 0%) and therapeutic interventions (2013 ACCF/AHA: 65%; 2017 ACCF/AHA/HFSA update: 64%; 2016 ESC: 16%) were not commonly included in CPGs. Patient context was included in about half of ACCF/AHA recommendations and a quarter of ESC recommendations. Conclusions The majority of recommendations from heart failure CPGs lack information on diagnostic and therapeutic performance parameters and patient context. Given the importance of these components to effectively implement EBM, particularly for a heterogeneous heart failure population, innovative strategies are needed to optimize CPGs so they provide comprehensive yet succinct recommendations that can improve population-level outcomes and ensure optimal patient-centered care.

Background In the phase III IMpassion130 trial, combining atezolizumab with first-line nanoparticle albumin-bound-paclitaxel for advanced triple-negative breast cancer (aTNBC) showed a statistically significant progression-free survival (PFS) benefit in the intention-to-treat (ITT) and programmed death-ligand 1 (PD-L1)-positive populations, and a clinically meaningful overall survival (OS) effect in PD-L1-positive aTNBC. The phase III KEYNOTE-355 trial adding pembrolizumab to chemotherapy for aTNBC showed similar PFS effects. IMpassion131 evaluated first-line atezolizumab–paclitaxel in aTNBC. Patients and methods Eligible patients [no prior systemic therapy or ≥12 months since (neo)adjuvant chemotherapy] were randomised 2:1 to atezolizumab 840 mg or placebo (days 1, 15), both with paclitaxel 90 mg/m2 (days 1, 8, 15), every 28 days until disease progression or unacceptable toxicity. Stratification factors were tumour PD-L1 status, prior taxane, liver metastases and geographical region. The primary endpoint was investigator-assessed PFS, tested hierarchically first in the PD-L1-positive [immune cell expression ≥1%, VENTANA PD-L1 (SP142) assay] population, and then in the ITT population. OS was a secondary endpoint. Results Of 651 randomised patients, 45% had PD-L1-positive aTNBC. At the primary PFS analysis, adding atezolizumab to paclitaxel did not improve investigator-assessed PFS in the PD-L1-positive population [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.60-1.12; P = 0.20; median PFS 6.0 months with atezolizumab–paclitaxel versus 5.7 months with placebo–paclitaxel]. In the PD-L1-positive population, atezolizumab–paclitaxel was associated with more favourable unconfirmed best overall response rate (63% versus 55% with placebo–paclitaxel) and median duration of response (7.2 versus 5.5 months, respectively). Final OS results showed no difference between arms (HR 1.11, 95% CI 0.76-1.64; median 22.1 months with atezolizumab–paclitaxel versus 28.3 months with placebo–paclitaxel in the PD-L1-positive population). Results in the ITT population were consistent with the PD-L1-positive population. The safety profile was consistent with known effects of each study drug. Conclusion Combining atezolizumab with paclitaxel did not improve PFS or OS versus paclitaxel alone. ClinicalTrials.gov NCT03125902.

This paper presents a competency model for mediating Industry 4.0 in Learning Factories. It allows assessing existing Learning Factories towards their readiness for Industry 4.0 competencies differentiated by social, technical, methodological, and personal aspects. Industry 4.0 has long since ceased to be an issue reserved solely for research. Companies are pursuing a wide variety of strategies in order to gain the advantages predicted by digitalisation and thus be able to stand up to global competition. In the meantime, there is also a general awareness in industry that the real implementation of such a strategy goes beyond the implementation of technologies and that above all the qualification of employees determine this success. Different models show the dimensions of Industry 4.0 that should be addressed in the qualification of employees. Here, Learning Factories are already recognized vehicles for the transfer of the respective competencies, which represent the link between theoretical knowledge and the practical ability of the learner. Nevertheless, there is hardly more detailed information available about the level of competencies and to which extend this level is beneficial along the stages of implementation of Industry 4.0 according to a comprehensive company strategy. On the example of a concept for an internationally distributed Learning Factory between Universities in Germany, Turkey, and Vietnam, the competency model is applied. We assess this Learning Factory network and show how and to what extend Industry 4.0 competencies can be achieved. Based on this analysis potential development stages for higher levels of Industry 4.0 competencies for the exemplarily chosen distributed Learning Factory are illustrated in order to cover the core requirements for the implementation of Industry 4.0 in industry.

BACKGROUND Arteriogenic erectile dysfunction is a common disease oftentimes not satisfactory treatable with medical therapy. AIM To assess the safety and clinical success rate of endovascular revascularization of erection-related arteries with the angiolite BTK stent in patients with arteriogenic erectile dysfunction. METHODS A total of 100 consecutive men (61.8������10��years) with atherosclerotic lesions in erection-related arteries agreed to participate and were included into a single-center all-comers registry. Endovascular therapy with angiolite BTK drug-eluting stents was performed on a total of 211 lesions. Patients received a baseline International Index of Erectile Function (IIEF)-15 questionnaire at first presentation and 3 and 12��months after stenting. An improvement by 4 points in the erectile function domain consisting of 6 questions (IIEF-6) was defined as minimal clinically important difference. A total of 24 patients with 52 stented arterial lesions underwent angiographic follow-up of the initially treated arterial side during secondary revascularization of the contralateral side (angiographic sub-study). OUTCOME Clinical improvement of erections in 100 patients undergoing endovascular revascularization of erection-related arteries. RESULTS No major adverse events occurred during endovascular revascularization or within 30��days thereafter. Technical success was achieved in all lesions and procedural success in all patients. At 1��year, 55 of 97 patients (56.7%) improved by at least 4 points in IIEF-6 score and thus achieved a clinically relevant improvement of erectile function.In the angiographic sub-study, arterial patency and binary restenosis were observed in 46 of 52 (88.5%) and in 8 of 52 (15.4%), respectively, after a mean follow-up of 9.6������5.8��months. CLINICAL IMPLICATIONS In patients with arteriogenic erectile dysfunction, endovascular therapy with a novel thin-strut sirolimus eluting stent is a safe and feasible treatment option. STRENGTHS & LIMITATIONS This real-world arterial revascularization registry included patients with a multitude of risk factors for ED, thereby representing the heterogeneity in patients in the clinical practice, which is one of its strengths but also one of its weaknesses. Another strength was the focus being laid on analyzing outcomes of patients with arteriogenic ED using only a single endovascular device. Further studies are warranted to better define subgroups of patients with impaired clinical outcomes. CONCLUSION Within the present all-comers registry, endovascular therapy of erectile dysfunction with the angiolite BTK stent was shown to be a safe and feasible treatment option resulting in clinical improvement rates comparable to earlier clinical trials although also showing that further research is warranted to define patient subgroups with particular benefits of endovascular therapy. Sch��nhofen J, R��ber L, Kn��chel J, et��al. Endovascular Therapy for Arteriogenic Erectile Dysfunction With a Novel Sirolimus-Eluting Stent. J Sex Med 2021;18:315-326.

Resume Introduction Les metastases osseuses sont source de douleurs et alterent la qualite de vie des patients. La radiotherapie est un des traitements antalgiques de reference. L’objectif de cette etude etait de comparer les pratiques courantes d’un service de radiotherapie francais pour le traitement des metastases osseuses non compliquees avec les donnees de la litterature dans le but d’ameliorer et d’optimiser la prise en charge des patients. Materiel et methodes Une etude retrospective monocentrique des patients ayant beneficie d’une irradiation palliative de metastases osseuses non compliquees a ete menee. Resultats Quatre-vingt-onze patients ont beneficie de 116 radiotherapies de metastases osseuses non compliquees sur la periode etudiee, dont 44 hommes (48 %) et 47 femmes (52 %), âges en moyenne de 63 ans (25–88 ans). Les tumeurs primitives les plus frequemment retrouvees etaient mammaires (35 %), pulmonaires (16 %) et prostatiques (12 %). Les schemas therapeutiques utilises etaient dans 29 % des cas 30 Gy en dix fractions, dans 21 % des cas 20 Gy en cinq fractions, dans 22 % des cas 8 Gy en une seance et dans 28 % des cas 23,31 Gy en trois fractions en conditions stereotaxiques. L’etat general du patient (indice de performance selon l’Organisation mondiale de la sante et indice de Karnofsky) (p Conclusion Cette etude a montre que la population des patients analysee etait comparable aux populations de differentes etudes. Des facteurs predictifs de choix du schema therapeutique ont ete identifies. Le traitement non fractionne etait sous-utilise, alors que le traitement en conditions stereotaxiques etait de plus en plus prescrit, ce qui montre une evolution dans la prise en charge des patients.

Objectives There is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers. Design Multicenter retrospective observational cohort. Setting and Participants Consecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas. Methods The primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients’ characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC). Results Of 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%). Conclusions and Implications Two-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. Adoption of MedPAC's recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain.

Background Rupture of the anterior cruciate ligament (ACL) is one of the most common injuries of the knee. Common techniques for ACL reconstruction require a graft fixation using interference screws. Nowadays, these interference screws are normally made of titanium or polymer/ceramic composites. The main challenge of application of a fixation device made entirely of bioactive ceramic is in relation to the low strength of such materials. The purpose of this study was to evaluate a novel geometry for a fixation device made of pure hydroxyapatite for ACL reconstructions that can overcome some problems of the titanium and the polymer/ceramic screws. Methods Finite Element Analysis was used for optimization of the stress distribution in conventional interference screw geometry. For experimental evaluation of the new fixation device, ex vivo tests were performed. Results The innovative screw-like fixation device is characterized by multiple threads with a large thread pitch. The novel design enabled the insertion of the screw into the bone without the application of an external torque or a screwdriver. In turn, it also allowed for the use of low-strength and high-bioactivity materials, like hydroxyapatite. Ex vivo tests showed that the novel screw can sustain pull-out forces up to 476 N, which is comparable to that of the commercially available BioComposite™ interference screws (Arthrex Inc., Germany), as a reference. Conclusions In summary, the novel screw design is a promising strategy to develop all-ceramic fixation devices for ACL reconstructions, which may eliminate some drawbacks of the current interference screws.

Aim To analyse the incidental findings during computed tomographic angiography (CTA) diagnostic work-up in patients with arteriogenic erectile dysfunction (ED). Patients and methods The medical records of all patients with suspected arteriogenic ED were entered into a database. Risk factors and underlying comorbidities were also collected. Pathological CTA findings were extracted from the CT readings and entered into the database. Incidental findings on CTA were classified as those requiring immediate medical treatment, requiring deferred medical treatment or of no clinical importance. Results A total of 200 patients underwent CTA for suspected arteriogenic ED. Mean patient age was 59.6 p 11.7 years. Of these, 181 patients (90.5%) had obstructions of erection-related arteries. In 168 patients (84.0%), CTA showed multiple incidental pathological findings. Eighty-five of 200 patients (42.5%) exhibited incidental findings requiring immediate further medical workup and/or treatment: coronary artery calcification was diagnosed in 75/200 (37.5%), aorto-iliac aneurysms in 8/200 (4%) of patients and incidentally detected embolism in 1/200 patient. Pancreatic and liver tumours were less frequent (incidence 1.5% and 1%, respectively). Incidental findings requiring deferred medical workup and/or treatment were detected in 175/200 patients (87.5%). The findings with the highest prevalence were liver steatosis followed by colon diverticulosis and prostate hyperplasia. Findings of little to no clinical importance were reported in 117 (58.5%) patients. These included uncomplicated renal cysts, spinal degeneration and renal vascular anomalies. Almost every second patient presenting with ED had an incidental finding which required immediate treatment. Conclusions Incidental findings not directly related to ED were common among patients undergoing CTA scans for suspected arterial obstructions. Coronary artery calcification was the leading finding requiring further medical workup and/or treatment. Thus, the benefit of CTA investigations extends beyond the anatomic description of arterial obstructions of erection-related arteries.

This study assesses whether American Thoracic Society clinical practice guidelines are substantiated by high-quality evidence and can be used to promote evidence-based medicine.

Purpose: To report the 1-year outcomes of a single-center, all-comers registry aimed to assess effectiveness and safety of endovascular revascularization for atherosclerotic erectile dysfunction (ED) in an unselected patient cohort. Materials and Methods: Between April 2016 and October 2017, 50 consecutive patients (mean age 59.6±10.3 years) underwent endovascular revascularization for ED owing to >50% stenosis in 82 erection-related arteries. Patients were treated by means of standard balloon angioplasty (16%), drug-coated balloon angioplasty (27%), or drug-eluting stent (55%) implantation. The primary feasibility outcome measure was the incidence of a minimum clinically relevant improvement of ≥4 in the 6-question International Index of Erectile Function Questionnaire (IIEF-6) score at 12 months. Clinical effectiveness was improvement in erectile function as quantified in the mean difference (MD) of the IIEF-15 score at 3 and 12 months as well as the mean changes in IIEF-15 questions 3 and 4. Results: Procedure success was achieved in 49 (98%) of 50 patients. At 12 months, 30 (65%) of 46 patients achieved a minimum clinically relevant improvement in the IIEF-6 score. The overall IIEF-15 score, as well as scores for questions 3 and 4, improved in 32 (65%) of 49 patients, 28 (57%) of 49 patients, and 29 (60%) of 48 patients, respectively. Change in the overall IIEF-15 score at 12 months was consistent among subgroups, except for elderly patients [MD −5.0 (95% CI −9.7 to −0.2), p=0.041] and those with hypertension [MD −11.0 (95% CI −20.5 to −1.5), p=0.025], who showed less improvement. Conclusion: Endovascular revascularization was safe and efficacious in the majority of ED patients through 1 year.

Background: Bone marrow is one of the organs at risk of complications during irradiation due to its radiosensitivity. Hematopoietic toxicity remains one of the main toxicities during irradiation of pelvis. Modern radiotherapy techniques, such as intensity modulation and three-dimensional conformal radiotherapy, allow for better dose compliance in target volumes while optimally sparing organs at risk. There is a lack of prospective studies and comparative trials specifying the dose constraints according to the presence or absence of chemotherapy and correlating with the patient’s bone marrow potential.Methods: This monocentric and prospective study conducted by the Strasbourg Europe Cancerology Institute aims to evaluate the hematological toxicity in patients treated with pelvic irradiation for prostate, rectum, anal canal, endometrium, or cervix cancer. One hundred patients will be included. The primary objective is to quantify the relationship between acute hematological toxicity and delivered doses and irradiated volumes in pelvic bone marrow for pelvic cancers. The prescribed dose to the pelvis depends on the tumor location, from 25 Gy in 5 fractions for rectal cancer to 78 Gy in 39 fractions for low-risk prostate cancer. Hematological toxicity will be measured by weekly blood count during radiotherapy and at one month and three months after the end of radiotherapy.Conclusions: The aim of this study is to improve and optimize radiotherapy if a dose limit or volume constraint is imposed by the results of the study. To our knowledge, this is the first study including several types of pelvic cancers and involving patients treated exclusively with radiotherapy, chemoradiotherapy or radiohormonotherapy.Trial Registration: Trial registration number is NCT04626466.

Background To assess relevance of ESMO-ESSO-ESTRO treatment guidelines in a retrospective analysis of patients with anal canal or anal margin cancers. Material and methods 155 patients were separated into standard treatment group (STG), treated according to or closely the guidelines, and an altered treatment group (ATG). Results The median follow-up time was 50.7 months. In the STG, the 5- and 10-year LR-DFS rates were 75.2% and 72.7%; in the ATG, they were 66.8% and 61.2%, respectively. In the STG, the 5- and 10-year OS rates were 81.8% and 68%; in the ATG, they were 63.3% and 49.5%, respectively (p = 0.037). In the multivariate analysis, favorable prognostic factors for OS included the standard treatment, age 50.4 Gy. Conclusion This study identifies the superiority of treatment according to standard guidelines compared to altered treatment. Our results corroborate the guidelines.

Purpose: To evaluate the incidence of elastic recoil in patients presenting with erectile dysfunction (ED) undergoing endovascular revascularization of the pudendal or penile arteries. Methods: A consecutive series of 21 ED patients (mean age 58.3±9.3 years) undergoing minimally invasive revascularization of 31 arteries was analyzed. ED lesions included the pudendal arteries (n=27) and the penile artery (n=4). Mean lesion length was 20.6±13.9 mm. Minimal lumen diameter (MLD) measurements were assessed at baseline, immediately after balloon angioplasty, and 10 minutes thereafter. Early recoil was defined as an MLD reduction >10%. Elastic recoil with >10% lumen compromise was treated with drug-coated balloons, while severe elastic recoil (>30%) required drug-eluting stents (DES). The International Index of Erectile Function (IIEF-15) score was obtained prior to and 3 months after the procedure to obtain information on functional outcomes subsequent to angioplasty. Results: Mean MLD at baseline was 0.9±0.6 mm, which improved to 2.0±0.9 mm immediately after balloon dilation. At 10 minutes after dilation, the MLD was 1.7±1.0 mm. Elastic recoil was observed in all 31 lesions and resulted in a mean lumen compromise of 21.2%. Severe (>30%) recoil was observed in 14 arteries, which underwent DES therapy. The IIEF-15 score improved from 31.3±11.2 at baseline to 49.8±16.8 (p

Purpose To analyse if BCG treatment leads to long-term reduction of recurrence, progression, and cancer-specific mortality (CSM) in patients with high-risk NMIBC. Materials and methods 140 patients with high-risk NMIBC were drawn from a population-based cohort of 538 patients with newly diagnosed bladder cancer in the Stockholm County between 1995 and 1996. Data were collected prospectively, and a final follow-up for recurrence, progression, and CSM was performed after 15 years. Patients that received BCG were compared with patients who did not receive BCG. Survival analysis was done with Kaplan–Meier estimates and Mantel–Cox log-rank test. Multivariable Cox proportional regression with stepwise selection was performed to verify the statistical significance of clinicopathological factors of prognostic importance. Results were displayed in Hazard ratios and a p

Introduction To apply evidence-based medicine (EBM) to individual patients and implement shared decision-making, it is necessary for clinical practice guidelines (CPGs) to incorporate performance metrics for diagnostic studies and therapeutic interventions, as well as relevant patient contexts. This is especially important in heart failure (HF), which is a highly heterogeneous population with a high prevalence of multimorbidity, and impairments in other domains (e.g. function and cognition) that can significantly impact the value of diagnostic studies and therapeutic interventions. We sought to determine the extent to which performance metrics and patient context are incorporated into major HF CPGs. Methods We reviewed the main and supplementary documents of 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) CPG, 2017 ACCF/AHA/HFSA update, and 2016 European Society of Cardiology (ESC) CPG. We assessed the following domains from each recommendation: performance metrics including sensitivity/specificity, positive/negative predictive value, number needed to treat, absolute benefit/harm, and time horizon to benefit; and patient context, including comorbidity, socio-personal milieu, personal preferences, and life expectancy. Results We examined 169 recommendations from the 2013 ACCF/AHA CPG and 2017 update, and 187 recommendations from the 2016 ESC CPG. Performance metrics for diagnostic studies were rarely included; metrics for therapeutic interventions were included to a varying degree depending on the CPG (Figure). Sensitivity/specificity, time horizon to benefit, and absolute benefits were mentioned in 7%, 13%, and 30% of all recommendations, respectively. Patient context was included in over 60% of ACCF/AHA/HFSA CPG recommendations but only included in 25% of the ESC CPG recommendations (Figure). Conclusion The majority of recommendations from HF CPGs lack granular information on diagnostic and therapeutic performance metrics. Contextual patient factors are also inconsistently included. These findings indicate that while HF CPGs may be evidence-based, they are not yet patient-centered. Given their importance to effectively implement EBM and shared decision-making among the complex and heterogeneous HF population, future CPGs should explicitly incorporate these aspects.

The aim of this study was to determine by computed tomography (CT) whether treatment with tumor-draining lymph-node-derived expanded autologous T lymphocytes results in objective responses and/or improved survival in patients with metastatic urinary bladder cancer (UBC) and to record the toxicity of the treatment.Eighteen patients with metastatic UBC were prospectively selected from two centers. The preoperative staging was T2-T4bN1-2 and/or M0-M1 or MX. Tumor-draining lymph nodes were harvested at intended cystectomy for the extraction of T lymphocytes. This was followed by expansion of the T lymphocytes in a cell culture, and subsequent reinfusion of these autologous tumor-specific T lymphocytes. Responses to therapy were evaluated by CT scans according to Response Evaluation Criteria In Solid Tumors (RECIST) and clinical follow-up, according to the research protocol.Nine out of 18 patients were treated. Treatment was feasible and safe. In two out of nine immunologically treated patients, objective responses were detected in terms of diminished or obliterated nodal metastases. When excluding three patients with disseminated osseous metastases plus one with a T4b tumor left in situ, a success rate of two out of six treated patients was seen. The two responders had survival times of 35 and 11 months, respectively. No toxicity was recorded.Infusion of expanded autologous tumor-specific T lymphocytes is feasible and safe, and objective responses according to RECIST were recorded. One objective responder to immunotherapy displayed notably long overall survival.

Post-operative management of pIIIA-N2 non-small cell lung cancer (NSCLC) is still debated. Our objective was to identify subgroups of patients who could benefit from treatment based on invaded lymph node ratio (LNR). From January 2003 to December 2012, 297 pIIIA-N2 NSCLC patients treated with surgery followed by conformational radiation therapy (RT) were retrospectively analysed. Median follow-up time was 30 months. A correlation was observed between LNR and overall survival (OS) (R = −0.3, p

Abstract. Erectile dysfunction (ED) is an evolving health problem with growing incidence in the ageing male population with potentially predictive value for cardiovascular and other chronic diseases. ED shares the common cardiovascular risk factors. The aetiology of ED is numerous including neurogenic, psychogenic, arteriogenic, and venogenic reasons. The origin of arteriogenic ED is frequently atherosclerosis. Patients not adequately responding to conservative measures including oral medication are often referred to further vascular diagnostics and therapy. At present, the refinements in endovascular therapy allow for minimal-invasive revascularization of erection-related arteries. The role of endovascular therapy in the complex framework of the multifactorial causes of ED requires further scientific scrutiny.

Facilities treating substance abuse problems have a unique opportunity to provide services related to intimate partner violence (IPV). This study investigated the percentage of substance abuse treatment facilities that offer IPV related services among a sample of over 10,000 treatment facilities. Characteristics of treatment facilities that do versus do not offer IPV services were also examined. Survey questions from the 2011 National Survey of Substance Abuse Treatment Services (NSSATS) were analyzed. Only a minority of facilities offered IPV related services (38.4 %). Additionally, compared to facilities not providing IPV services, those providing such services differed on many notable characteristics, such as gender of clients accepted into the program (programs focused on adult women were more likely to offer IPV services), facility location (IPV services offered more in the Western United States), and facility ownership (IPV services offered more in facilities owned by tribal governments).

The aim of this study was to determine the efficacy of combined [(11)C]acetate positron emission tomography and computed tomography ([(11)C]acetate-PET/CT) in regional lymph-node staging in patients with prostate cancer (PCa).[(11)C]Acetate-PET/CT was performed in 19 PCa patients who subsequently underwent extended pelvic lymph-node dissection (ePLND). The [(11)C]acetate-PET/CT results were compared with the surgical and histopathological findings from 13 defined lymph-node regions.[(11)C]Acetate-PET/CT was true-positive for lymph-node metastases in nine patients, false-positive in three, false-negative in one patient and true-negative in six. The patient-by-patient-based sensitivity was 90% and the specificity 67%, the positive predictive value (PPV) was 75% and the negative predictive value (NPV) 86%. From a total of 114 nodal regions (mean 5.9 regions per patient), 484 lymph nodes (mean 25.5 nodes per patient) were removed and evaluated histopathologically. Forty-six lymph nodes from 24 out of 114 (21%) nodal regions were positive for PCa metastasis. The nodal-region-based sensitivity of [(11)C]acetate-PET/CT was 62%, specificity was 89%, PPV 62% and NPV 89%.[(11)C]Acetate-PET/CT detects PCa lymph-node metastases with high patient-by-patient-based sensitivity but low specificity, and low nodal-region-based sensitivity but high specificity. Its limited ability to detect microscopic lymph-node involvement makes ePLND essential in all patients diagnosed with positive nodes on [(11)C]acetate-PET/CT.

Purpose: to evaluate the role of whole brain radiotherapy (WBRT) and radiation boost (RB) for 208 patients recursive partitioning analysis (RPA) II with 1 or 2 brain metastases (BM) at a single institution. Methods and Materials: the dose of WBRT was 30 Gy (10 fractions of 3 Gy). One hundred thirty-two patients (63.5%) benefited from RB of 9 Gy in 3 fractions of 3 Gy at the metastatic site. Patients had 1 or 2 BM in 122 (58.7%) and 86 cases (41.3%), respectively. Results: patients with one or two metastases had similar survival (4.6 and 5.1 months, respectively) (p = 0.4). Median overall survival (OS) for patients treated with WBRT and RB, and with WBRT alone was 5.9 and 3.7 months, respectively (p = 0.03). The 6-, 12- and 24-month OS rates after WBRT and RB were 48.5%, 25% and 10.6%, respectively, while WBRT alone resulted in OS rates of 34%, 22.4% and 3.2%, respectively (p = 0.03). After WBRT and RB, the 6-, 12- and 24-month local control rates were 92%, 82% and 67%, respectively, while they were 81.2%, 75% and 37.5%, respectively, after WBRT alone (p = 0.03). The 6-, 12- and 24-month brain control rates after WBRT and RB were 88.7%, 75.8% and 62%, respectively, and after WBRT alone they were 78.5%, 59% and 37.7%, respectively (p = 0.03). Conclusion: additional boost delivered with 3D conformal radiotherapy improves local and brain control rates significantly as well as overall survival for RPA II patients with 1 or 2 unresectable BM.

Objective To evaluate the effect of the learning curve on operative, postoperative, and pathological outcomes of the first 67 totally intracorporeal robot-assisted radical cystectomies (RARCs) with neobladders performed by two lead surgeons at Karolinska University Hospital. Patients and Methods Between December 2003 and October 2012, 67 patients (61 men and six women) underwent RARC with orthotopic urinary diversion by two main surgeons. Data were collected prospectively on patient demographics, peri- and postoperative outcomes including operation times, conversion rates, blood loss, complication rates, pathological data and length of stay (LOS) for these 67 consecutive patients. The two surgeons operated on 47 and 20 patients, respectively. The patients were divided into sequential groups of 10 in each individual surgeon's series and assessed for effect of the learning curve. Results Patient demographics and clinical characteristics were similar in both surgeons' groups. The overall total operation times trended down in both surgeons' series from a median time of 565 min in the first group of 10 cases, to a median of 345 min in the last group for surgeon A (P < 0.001) and 413 to 385 min for surgeon B (not statistically significant). Risk of conversion to open surgery also decreased with a 30% conversion rate in the first group to zero in latter groups (P < 0.01). Overall complications decreased as the learning curve progressed from 70% in the first group to 30% in the later groups (P < 0.05), although major complications were not statistically different when compared between the groups. Patient demographics did not change over time. The mean estimated blood loss was unchanged across groups with increasing experience. The pathological staging, mean total lymph node yield and number of positive margins were also unchanged across groups. There was a decrease in LOS from a mean of 19 days in the first group to a mean (range) of 9 (4–78) days in the later groups, although the median LOS was unchanged and therefore not statistically significant. Conclusions Totally intracorporeal RARC with intracorporeal neobladder is a complex procedure, but it can be performed safely, with a structured approach, at a high-volume established robotic surgery centre without compromising perioperative and pathological outcomes during the learning curve for surgeons. An experienced robotic team and mentor can impact the learning curve of a new surgeon in the same centre resulting in decreased operation times early in their personal series, reducing conversion rates and complication rates.

Resume Objectif de l’etude Du fait de bons resultats en termes de controle local et de tolerance, la radiotherapie hypofractionnee en conditions stereotaxiques s’est imposee ces dernieres annees comme un nouveau standard therapeutique pour les patients atteints d’un carcinome bronchique non a petites cellules de stade I, juges inoperables ou chez des patients qui refusent la chirurgie. Cette technique de traitement a ete implementee au centre Paul-Strauss a Strasbourg en 2010. L’objectif de cette etude etait de decrire et d’analyser les donnees des 20 premiers patients traites. Patients et methodes D’octobre 2010 a mai 2012, 20 patients ont ete traites par cette technique pour une tumeur pulmonaire primitive classee T1N0M0 ou T2N0M0. L’indication a ete proposee en reunion de concertation pluridisciplinaire d’oncologie thoracique et validee par le comite technique du departement de radiotherapie. Apres reperage par une scanographie dosimetrique en trois sequences ou quadridimensionnelle et apres realisation d’une TEP au ( 18 F)-fluorodesoxyglucose en position de traitement, tous les patients ont ete traites avec un accelerateur lineaire de type Novalis Tx ® , par une technique d’arctherapie ou de radiotherapie conformationnelle avec modulation d’intensite (RCMI). Un protocole a ete defini concernant la dose prescrite, selon la taille et la localisation tumorale, centrale ou peripherique. Les patients ont beneficie d’un suivi pendant le traitement puis a un mois, trois a quatre mois, six et neuf mois pour evaluer les resultats et la toxicite. Resultats L’âge moyen etait de 72,6 ans (52–89). Dix-sept patients souffraient d’une ou plusieurs « comorbidites » pulmonaires. La dose moyenne delivree etait de 59,9 Gy (40–70) en fractions de 4 a 17,5 Gy. Le volume tumoral macroscopique moyen (GTV) etait de 14,9 mL (mediane 7,2 ; 0,9–73,5) et le volume cible previsionnel moyen etait de 77,8 mL (mediane 49,5 ; 17–300). La standard uptake value (SUV) maximale initiale moyenne etait de 7,7 (1,8–16,7). Les contraintes de doses et de couverture recommandees par le protocole etaient atteintes dans la majorite des cas. Le volume recevant 20 Gy (V20) pulmonaire etait en moyenne de 7,63 % (1,2–17,7) et la dose moyenne delivree au volume cible previsionnel de 94,6 % (88–99). La duree moyenne du traitement etait de 21 jours (mediane : 23 ; 8–27), et aucune modification de l’etalement prescrit ni interruption de traitement n’est survenue. Le suivi median etait de 6,6 mois, et les taux bruts de reponse objective pour les patients qui ont pu beneficier d’une evaluation de 85 % (11/13 patients) a trois mois et 100 % a six et neuf mois. Les taux de reponse complete a trois et six mois etaient de 0 (0/13 patients) et 50 % (5/10 patients). Deux patients ont ete atteints d’une evolution metastatique a distance dans les six mois qui ont suivi le traitement. En ce qui concerne la tolerance pulmonaire a trois mois, six patients ont souffert d’une pneumopathie de grade 2 et trois de grade 3, d’evolution favorable. Conclusion L’analyse des premiers resultats de cette serie, comparables a ceux decrits dans la litterature, montre que la radiotherapie pulmonaire en conditions stereotaxiques est efficace et bien toleree chez des patients fragiles. L’extension des indications pourrait etre envisagee en fonction des resultats des essais en cours.

Resume Objectif de l’etude Comparer l’influence de la dose d’irradiation, haute dose contre dose standard, sur la survie apres une chimioradiotherapie exclusive pour cancer de l’œsophage. Patients et methodes De 2003 a 2006, les dossiers de 143 patients consecutifs atteints d’un carcinome epidermoide ou d’un adenocarcinome de l’œsophage, de stade I a IVA, traites dans deux institutions, ont ete retrospectivement analyses. Quatre-vingt-trois patients ont recu plus de 50,4 Gy, en mediane 66 Gy (50,7–72 Gy), et 60 patients 50,4 Gy ou moins, en mediane 50 Gy (38–50,4 Gy). Resultats L’âge moyen etait plus eleve dans le groupe irradie a haute dose (67,6 contre 61,7 ans). Le statut nutritionnel et le stade etaient meilleurs dans ce groupe avec une perte de poids moindre (5,1 contre 7,9 %), un indice de masse corporel plus eleve (25,7 contre 22,9), plus de cancers de stade N0 (60,2 contre 31,7 %) et moins de cancers de stade III (27,7 contre 63,3 %). Le suivi median etait de 20,8 mois (2,8–92,4 mois), et de 64,9 mois (4,2–92,4 mois) pour les 33 survivants. Les taux de survie sans recidive locale, sans recidive locoregionale, sans metastase et sans maladie n’etaient pas significativement differents. Les taux de survie globale a 24, 36, 60 mois et la duree mediane de survie etaient respectivement de 44,7 %, 36,8 %, 19,1 % et 21,2 mois dans le groupe irradie a haute dose et de 50,8 %, 31,6 %, 20,7 % et 24,6 mois dans le groupe irradie a dose standard (p = 0,9). Conclusion Aucune difference n’a pu etre mise en evidence entre les deux groupes en termes de controle local et locoregional (ganglionnaire), de metastases a distance, de survie sans maladie et de survie globale. Une etude randomisee est necessaire.

Objective: To analyze different polyunsaturated fatty acid (PUPA) tissue levels in malignant compared with benign prostatic tissue from the same prostate specimens. Materials and methods: Fresh frozen benign and malignant prostatic tissue was obtained from radical prostatectomy specimens in 49 men with pathologic stage pT2a prostate cancer. Histopathologic examination confirmed that all tissues from each prostate being analyzed were either completely benign or almost totally malignant. The PUFA composition in these tissues was determined by gas-liquid chromatography on a capillary column. The relative amount of each PUFA (% of total fatty acids) was quantified by integrating the area under the peak and dividing the result by the total area of all fatty acids. Results: Tissue levels of dihomo-gamma-linolenic acid, (C20:3w6), an omega-6 PUFA and a major precursor of omega-6 PUFA metabolites, were significantly higher in malignant compared with benign tissues (P = 0.002). Tissue levels of the downstream omega-6 metabolites, arachidonic acid (AA) (20:4 omega 6), and adrenic acid, (22:4 omega 6), were significantly lower in cancer tissues, (P < 0.0001 and P = 0.013, respectively). Overall, the total levels of omega-6 PUPA were lower in cancer (P = 0.001). Conclusion: We found that the omega-6 PUPA AA and adrenic acid are decreased in malignant prostatic tissues compared with benign tissues from the same prostates. These findings provide additional evidence that dietary fat is associated with prostatic carcinogenesis.

We present results on the growth of CdTe-HgTe core-shell nanowires, a realization of a quasi-one-dimensional heterostructure of the topological insulator HgTe. The growth is a two step process consisting of the growth of single crystalline zinc blende CdTe nanowires with the vapor-liquid-solid method and the overgrowth of these wires with HgTe such that a closed shell is formed around the CdTe core structure. The CdTe wire growth is monitored by RHEED allowing us to infer information on the crystal properties from the electron diffraction pattern. This information is used to find and control the optimal growth temperature. High quality single crystal CdTe nanowires grow with a preferred orientation. For the growth of the conductive HgTe shell structure we find that the supplied Hg:Te ratio is the crucial parameter to facilitate growth on all surface facets.

Background: Surgery for anal canal cancer (ACC) and anal margin cancer (AMC) is the only curative option after failure of chemoradiotherapy (CRT). This study aimed to determine the efficacy of surgery for ACC or AMC after failed CRT. Methods: This was a single-centre, retrospective study of 161 patients initially treated with CRT. We compared the survival rates of patients successfully treated by CRT with those of patients whose CRT failed (both surgically salvaged and treated palliatively). Results: Thirty-one patients underwent surgery with curative intent, 20 received palliative treatment after failure of CRT, and 110 had effective CRT. The 5-year overall survival (OS) rate was significantly higher among patients with successful CRT than among patients who underwent surgery with curative intent (86 vs. 66%, p < 0.001). On the other hand, the 5-year OS of patients treated with curative surgery was significantly better than that of patients who underwent palliative treatment (66 vs. 13.5%, p < 0.001). The postoperative morbidity and mortality rates were 32 and 3%, respectively. Considering patients with failed CRT, curative surgery was the only factor prognostic of favourable OS in the multivariate analysis. Conclusion: Curative surgery after failure of CRT for ACC or AMC remains an effective treatment to improve survival in two-thirds of cases, resulting in high but manageable morbidity.

A 71-year-old female patient with a status following multiple conjunctival excisions, histopathologically confirmed conjunctival melanoma (CMM) and also multiple therapy with mitomycin C presented with progressive conjunctival pigmentation. Treatment was carried out with local interferon α2b administration four or five times daily for several months. The lesion showed regression and lost pigmentation without any side effects.

Summary Identify prognostic factors for survival and patterns of treatment failure after definitive radiochemotherapy for esophageal cancer. Between 2003 and 2006, 143 patients with squamous cell carcinoma and adenocarcinoma of the esophagus were retrospectively reviewed. Median age was 65 years (42–81). Median radiation dose was 62.5 Gy (38–72) with 1.8–2 Gy fraction. Median follow-up was 20.8 months (2.8–92.4). Three and 5-year local recurrence-free survival rates were 58.3% and 50.9%. In univariate analysis, traversable esophageal stricture was a prognostic factor. Three, 5-year locoregional recurrence-free survival rates were 42.4% and 34.9%. In multivariate analysis, traversable esophageal stricture and stage < IIB were independent prognostic factors. Three and 5-year disease-free survival rates were 30.5% and 25.9%. In multivariate analysis, Nutritional Risk Index (NRI) ≥ 97.5 and performance status (PS) = 0 were independent prognostic factors. Median, 3, and 5-year overall survival rates were 22.1 months, 34.4%, and 19.8%. In multivariate analysis, independent prognostic factors were NRI ≥ 97.5 and PS = 0. Median survival times for the NRI classes (no denutrition, moderate and severe denutrition) were 29.5, 19.7, and 12 months (P = 0.0004), respectively. A major impact of baseline NRI was found in terms of survival; it should be included in future prospective trials.

Die aktuelle S3-Leitlinie zur Diagnostik und Therapie des Magenkarzinoms einschlieslich der Adenokarzinome des osophagogastralen Ubergangs beschreibt die bestmoglichen Versorgungsmodalitaten basierend auf hoher Evidenz und interdisziplinarem Konsens verschiedener medizinischer Fachgebiete. Die Osophagogastroduodenoskopie mit Entnahme multipler Biopsien ist als Standardverfahren zur Detektion von Tumoren im oberen Gastrointestinaltrakt anzusehen. Zum Staging werden weitere bildgebende Untersuchungsverfahren eingesetzt. Die Chirurgie stellt weiterhin bis auf die mukosabeschrankten Tumoren die entscheidende Behandlungsoption mit kurativem Ansatz bei allen potenziell resezierbaren Stadien dar.

Transmission electron microscopy (TEM) and scanning electron microscopy (SEM) have been carried out to clarify the microstructure of Bi2Se3 thin films grown by molecular beam epitaxy (MBE) on Si(111) and InP(111) substrates. The film grown on InP displays much better overall quality at the microstructural level than does the film grown on the Si substrate. A layer of poor crystalline quality at the interface followed by well-crystallized Bi2Se3 has been observed for both substrates. The thickness of this interface layer is not uniform; it varies across the sample from zero, showing a sharp interface between the substrate and Bi2Se3, up to ∼1 nm and ∼1.8 nm for Bi2Se3/InP and Bi2Se3/Si, respectively. Formation of rotation twin domains and lamellar twins has been observed and is described in detail for both substrates.

Resume Nous rapportons le cas d’un patient âge de 40 ans tabagique suivi pour un adenocarcinome de l’apex pulmonaire gauche, metastatique d’emblee au niveau musculaire avec extension a la corticale du femur droit, traite par exerese chirurgicale de la masse de la cuisse et enclouage centro-medullaire femoral, et par six cures de chimiotherapie (cisplatine-vinorelbine) associees a une radiotherapie thoracique concomitante. Un bilan de fin de traitement objectivait une stabilite tumorale sur l’ensemble des cibles. Un an plus tard, une hematurie macroscopique amenait a decouvrir une masse tumorale de la vessie. Les biopsies par cystoscopie concluaient a un adenocarcinome d’origine pulmonaire. Le PET-scanner montrait une hyperfixation de la masse vesicale, un hypermetabolisme surrenalien droit et sous-cutane scapulaire gauche. Le patient a alors beneficie d’une cystectomie partielle associee a une entero-cystoplastie et reimplantation ureterale gauche et d’une exerese de la masse sous-cutanee scapulaire gauche, ainsi que d’une surrenalectomie droite lors du meme temps operatoire. L’anatomopathologie concluait a un adenocarcinome d’origine pulmonaire au niveau de la vessie, du nodule sous-cutane scapulaire gauche et de la surrenale droite. Une chimiotherapie par carboplatine et pemetrexed a ete initiee. Ce cas clinique illustre un site metastatique vesical tres inhabituel pour le cancer bronchique. A partir de ce cas et a la lumiere de quelques donnees de la litterature, nous tenterons de discuter les limites des examens complementaires et de proposer des attitudes therapeutiques.

Background Robot-assisted radical cystectomy (RARC) may reduce morbidity after cystectomy. Descriptions of the surgical techniques of RARC with intracorporeal orthotopic neobladder or ileal conduit are sparse and oncologic and functional outcome data have not been reported. Objective We present our technique with RARC and intracorporeal urinary diversion (neobladder or ileal conduit) and present oncologic and functional outcomes, as well as complication rates. Design, setting, and participants Single-hospital institution case-series from 2004 to 2009 including 45 selected patients (38 male, 7 female) with high-grade and/or muscle-invasive urothelial cancer of the bladder. Surgical procedure We performed RARC; pelvic lymph node dissection using three different templates; and a totally intracorporeal urinary diversion, either orthotopic neobladder ( n =36) or ileal conduit ( n =9). Measurements Perioperative variables, pathology data, early and late complication rates, urinary continence, potency, and cancer-specific survival were evaluated as outcome measures. Results and limitations Median patient age, operative time, estimated blood loss, and lymph node yield were 62 yr (range: 37–79), 477min (range: 325–760), 550ml (range: 200–2200), and 19 (range: 10–52), respectively. Nine patients were diagnosed with positive lymph nodes. Surgical margins were clear in all but one patient. Early complications occurred in 18 patients (40%). Median postoperative stay was 9 d (range: 4–78), and median postoperative follow-up time was 25 mo. Four patients died due to metastatic disease. The study is limited by a relative small sample size and no comparative group. Conclusions RARC with totally intracorporeal urinary diversion is technically feasible with good intermediate-term oncologic results. This is a nonrandomised study including a limited number of patients with a restricted follow-up time, however, and so precautions must be considered when interpreting the outcomes.

OBJECTIVE To identify predictors for long-term urinary leakage after radical prostatectomy. PATIENTS AND METHODS A consecutive series of 1411 patients who underwent radical prostatectomy (open surgery or robot-assisted laparoscopic surgery) at Karolinska University Hospital between 2002 and 2006 were invited to complete a study-specific questionnaire. Urinary leakage was defined as use of two or more pads per day. RESULTS Questionnaires were received from 1288 (91%) patients with a median follow-up of 2.2 years. Age at surgery predicts in an exponential manner long-term urinary incontinence at follow-up with an estimated relative increase of 6% per year. Among the oldest patients, 19% had urinary incontinence compared with 6% in the youngest age group, translating to a prevalence ratio of 2.4 (95% confidence interval [CI], 1.5-8.1). Low educational level, as compared with high, yielded an increased age-adjusted prevalence ratio of 2.5 (95% CI, 1.7-3.9). Patients who had undergone salvage radiation therapy had an increased prevalence of urinary incontinence (2.5; 95% CI, 1.6-3.8), as did those with respiratory disease (2.4; 95% CI, 1.3-4.4). Body mass index, prostate weight, presence of diabetes or previous transurethral resection did not appear to influence the prevalence of urinary incontinence. CONCLUSIONS In this series, a patient's age at radical prostatectomy influenced, in an exponential manner, his risk of long-term urinary incontinence. Other predictors are low educational level, salvage radiation therapy and respiratory disease. Intervention studies are needed to understand if these data are relevant to the prevalence of urinary leakage if a radical prostatectomy is postponed in an active monitoring programme.

Objectives To assess the surgery-related complications at robot-assisted radical cystectomy with total intracorporeal urinary diversion during our learning curve in treating 45 patients with bladder cancer. Methods A total of 45 patients were pooled in 3 consecutive groups of 15 cases each to evaluate the complications according to the Clavien classification. As a surrogate for our learning curve, the following parameters were assessed: operative time, blood loss, urinary diversion type, lymph node yield, surgical margin status, and length of hospital stay. Results Early surgery-related complications were noted in 40% of the patients and late complications in 30%. The early Clavien grade III complications remained significant (27%) and did not decline with time. Overall, fewer complications were observed between the groups over time, with a significant decrease in late versus early complications ( P = .005 and P = .058). The mean operative times declined from the first group to the second and third groups ( P = .005) and the hospital stays shortened ( P = .006). No significant difference was observed between groups regarding the lymph node yield at cystectomy ( P = .108), with a mean of 22.5 nodes (range 10-52) removed. More patients received an orthotopic bladder substitute (Studer) in each of the latter 2 groups than in the first. Conclusions Although robot-assisted radical cystectomy with total intracorporeal urinary diversion is a complex procedure, we observed decreased surgery-related complications and improved outcomes over time in the present series. Our results need to be confirmed by others before robot-assisted radical cystectomy with totally intracorporeal urinary diversion can be accepted as a treatment option for patients with bladder cancer.