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Objective: To evaluate the predictive validity of IRIS™ (Intuitive Surgical®, Sunnyvale, CA, USA) as a planning tool for robot-assisted partial nephrectomy (RAPN) by assessing the degree of overlap with intraoperative execution. Methods: Thirty-one patients scheduled for RAPN by four experienced urologists were enrolled in a prospective study. Prior to surgery, urologists reviewed the IRIS™ three-dimensional model on an iphone Operating System (iOS) app and completed a questionnaire outlining their surgical plan including surgical approach, and ischemia technique as well as confidence in executing this plan. Postoperatively, questionnaires assessing the procedural approach, clinical utility, efficiency, and effectiveness of IRIS™ were completed. The degree of overlap between the preoperative and intraoperative questionnaires and between the planned approach and actual execution of the procedure was analyzed. Questionnaires were answered on a 5-point Likert scale and scores of 4 or greater were considered positive. Results: Mean age was 65.1 years with a mean tumor size of 27.7 mm (interquartile range 17.5–44.0 mm). Hilar tumors consisted of 32.3%; 48.4% of patients had R.E.N.A.L. nephrometry scores of 7–9. On preoperative questionnaires, the surgeons reported that in 67.7% cases they were confident that they can perform the procedure successfully, and on intraoperative questionnaires, the surgeons reported that in 96.8% cases IRIS™ helped achieve good spatial sensation of the anatomy. There was a high degree of overlap between preoperative and intraoperative questionnaires for the surgical approach, interpreting anatomical details and clinical utility. When comparing plans for selective or off-clamp, the preoperative plan was executed in 90.0% of cases intraoperatively. Conclusion: A high degree of overlap between the preoperative surgical approach and intraoperative RAPN execution was found using IRIS™. This is the first study to evaluate the predictive accuracy of IRIS™ during RAPN by comparing preoperative plan and intraoperative execution.

Objective: In this study our objective was to develop a simulation platform for use cases in Laparoendoscopic Single Site (LESS) Surgery intended for patient-specific rehearsal prior to Robot-assisted Partial nephrectomy procedures. Patients and Surgical Procedure: This represents a simulation platform requiring no patients, although the fabrication process allows for the platform to be patient-specific. Tissue phantom 3D models were developed from de-identified CT imaging fulfilling the criteria of tumors located in the posterior lower pole of the kidney. Results: Respondents completed surveys on platform novelty and effectiveness. Agreement on simulator novelty was unanimously positive (100% agree or better). Performance evaluations reached a minimum of 80% agreement for all categories, with zero respondents Conclusions: We have developed a highly realistic simulation platform for use in single-port robot-assisted partial nephrectomy that can be produced in a patient specific manner, which we believe will be highly useful for trainees as well as experts attempting to transfer skills to the newer platform.

Background: The benefits of surgical simulation have been previously demonstrated to enhance technical skills resulting in improved outcomes. Complex procedures such as the percutaneous nephrolithotomy (PCNL) have a steep learning curve and have the potential to create an unsafe patient environment. Objective: To demonstrate a high fidelity and improved patient outcomes with hydrogel simulations for surgical rehearsals of a complex procedure (PCNL). Design, Setting, Participants: Between 2016 and 2017 a single surgeon performed 18 consecutive PCNLs, 10 prospectively, at an academic referral center Intervention: Anatomically correct models of the human pelvicalyceal system, kidney and relevant adjacent structures were created using poly-vinyl alcohol (PVA) hydrogels of the 10 prospective patients. DICOM images were converted to computer assisted designs and a patient specific model were created using 3-Dimensional printing and biomaterials technology. All PCNL steps were simulated: fluoroscopic access, nephroscopy, and lithotripsy. After surgical rehearsal the following day PCNL was performed by the trainee. Outcome Measurements and Statistical Analysis: Procedure specific metrics and patient outcomes were collected for all patients. Results and Limitations: There were significant differences in operative metrics (mean fluoroscopy time, the number of percutaneous access attempts, the number of times the needle was repositioned, and stone clearance) and patient outcomes (complications, length of stay and readmission rates). The study is limited by the sample size. Conclusions: This study demonstrates that patient-specific procedural rehearsal is effective for enhancement in the performance of a complex endourological procedure through the reduction in total operative and fluoroscopy times with improvement in patient outcomes. By incorporating this technology, medical practice would be following the route of other high-stakes industries in utilizing simulation to minimize complications for patients undergoing standard and more complex procedures and improving overall patient safety.

Background: Robot-assisted partial nephrectomy (RAPN) is becoming the standard treatment for small renal masses. However, the availability of realistic validated, non-biohazardous procedural platform for training are lacking for both generic and patient-specific training. Objective: The multi-institutional validation of a high-fidelity, perfused, inanimate, simulation platform for RAPN utilizing incorporated clinically relevant objective metrics of simulation (CROMS) applying modern validity standards. This concept was further developed into patient specific models for surgical rehearsals by converting patients axial imaging using image segmentation, mechanical testing of hydrogel components to realistically replicate the properties of live tissue and anatomical verification of models to patients’ original scans. Materials and Methods: Utilizing a combination of 3D printing and hydrogel casting a RAPN model was developed from a patient's C.T. scan with a 4.2 cm, upper-pole renal tumor (RENAL nephrometry score 7x). 3D-printed casts designed from the patient's imaging were utilized to fabricate and register hydrogel (Polyvinyl alcohol) components of the kidney including vascular and pelvicalyceal systems. Following mechanical and anatomical verification of the kidney phantom, it was surrounded by other relevant hydrogel organs and placed in a laparoscopic trainer. 27 novice and 16 expert urologists categorized according to caseload, from 5 academic institutions completed the simulation. Mechanical and functional testing protocols were completed to confirm that the properties of PVA matched the live tissue.5 Anatomical accuracy was confirmed by CT scanning the phantom and creating another CAD, which was compared to the original patient CAD. Full-procedural PS rehearsals were completed 24-48 hours prior to their respective live surgeries. Clinically relevant metrics (warm ischemia time, estimated blood loss, and positive surgical margins) from each rehearsal and live case were compared using a Wilcoxon-rank sum test. Results: Expert ratings demonstrated model’s superiority to other procedural simulations in replicating procedural steps, bleeding, tissue texture, and appearance. Significant difference between groups was demonstrated in CROMS [console time (p

Introduction: IRISTM is an interactive 3-D anatomic modeling software allowing functional manipulation of anatomical models for the surgical planning of renal masses. The software represent converted DICOM files of CT images to 3D virtual anatomical models, viewed on an iOS device during preoperative surgical planning and the da Vinci surgical system TilePro input for intraoperative navigation. The objective of this video is to demonstrate the clinical (utility/application) usefulness of IRIS as a preoperative planning and intraoperative navigation tool in 2 patients with highly complex renal masses. Methods: The first case is a 73 year old male patient with a 2.7cm right, completely endophytic hilar renal mass. Nephrometry score was 10h. The second case was a 45 years old male presenting with a 7.8 by 7.6 cm left hilar posterior renal mass with a nephrometry score of 11p. Two other cases demonstrate the utility of IRIS technology for selective and super-selective arterial ischemia. Preoperative planning was completed utilizing axial imaging and IRIS on an iOS device and a surgical plan put forth. Intraoperative navigation was via the da Vinci surgical system TilePro input. Perioperative and intraoperative patient data was collected. Results: In the first case IRIS helped visualize the resection cavity exposing the surrounding vascular branches that maybe injured during resection, identifying the feeding vessels perfusing the tumor and realizing structures that are likely to get injured during suturing the base of the resection bed during the renoprraphy sutures. Estimated Blood loss (EBL) was 100cc, Warm ischemia time (WIT) 17 minutes, with minimal change in postoperative renal function. In the second partially case with an exophytic tumor, the transparency function allowed for identification of vital structures that would be encountered at the resection base. In this case a large portion of the PCS and a feeding branch of the renal artery, which was accurately localized by altering parenchyma transparency. EBL was 60cc, WIT 28 minutes and GFR was maintained postoperatively. Pathology was positive for clear cell carcinoma with negative margins. In the final tow cases IRIS helped the surgeon accurately identify and dissect the 2ry and 3ry arterial branches supplying the tumor for selective ischemia. Conclusion: IRIS technology with its interactive features offered valuable pre and intraoperative information not attainable by standard axial imaging in the robotic management of complex renal masses.

Mixed farming systems are gaining interest both as a risk management strategy and to apply agroecological principles. This study set out to assess the sustainability of mixed systems compared to their specialized counterparts. The Orfee bioeconomic farm model was used to simulate three mixed farms: beef and dairy, beef and sheep, and cash crop and beef, under 1990–2017 prices and policies in France. Several sustainability criteria were computed at two scales (i) aggregated farm level, to assess whether mixed farms with several integrated enterprises performed better than if these enterprises were managed in specialized farms, and (ii) unit of product or labour to assess whether a product was produced more sustainably and a worker obtained higher and more stable income in a mixed farm. We found that mixed farms had less work peaks, lower global warming potentials and nitrogen balances, lower total production costs, higher and more stable net incomes than if their enterprises were managed in two specialized farms. However, profitability and income variability of the mixed farms were not better than the best performing specialized farm. The consumption of concentrate feed decreased in the mixed livestock farms but increased in the beef-crop farm that degraded feed-food competition.

Abstract Background Radical surgery is the first line treatment for localized prostate cancer (PC), however, several studies have demonstrated that surgical procedures induce tumor cell mobilization from the primary tumor into the bloodstream. Methods The number and temporal fluctuations of circulating tumor cells (CTC), cancer associated fibroblasts (CAF) and CTC cluster present in each blood sample was determined. Results The results show that both CTC and CTC cluster levels significantly increased immediately following primary tumor resection, but returned to baseline within 2 weeks post-surgery. In contrast, the CAF level decreased over time. In patients who experienced PC recurrence within months after resection, CTC, CAF, and cluster levels all increased over time. Based on this observation, we tested the efficacy of an experimental TNF-related apoptosis-inducing ligand (TRAIL)-based liposomal therapy ex-vivo to induce apoptosis in CTC in blood. The TRAIL-based therapy killed approximately 75% of single CTCs and CTC in cluster form. Conclusion Collectively, these data indicate that CTC cluster and CAF levels can be used as a predictive biomarker for cancer recurrence. Moreover, for the first time, we demonstrate the efficacy of our TRAIL-based liposomal therapy to target and kill prostate CTC in primary patient blood samples, suggesting a potential new adjuvant therapy to use in combination with surgery.

A duplicated collecting system is a common congenital anomaly of the urinary tract. However, late symptomatic presentation in adulthood is uncommon. We report the first case of left heminephrectomy, ureterectomy and radical prostatectomy using the da Vinci SP (single port) surgical system in a 64-year-old patient with localized prostate cancer and duplicated system with ectopic ureteral insertion into the prostatic urethra. The procedure was completed without technical difficulties or intraoperative adverse events. We demonstrate that the da Vinci SP robot allows for efficient performance of concomitant surgeries on the kidney and prostate without the limitations reported with single site surgeries.

Bladder cancer: stopping the spread Blocking the effects of the female hormone estrogen may increase the survival rate of women with bladder cancer (BCa). Although BCa is more common in men, tumors are more likely to invade neighboring tissues in women. Sex hormones and their receptors, which are known to affect progression of other cancers, may play a key role. A team led by Shuyuan Yeh at the University of Rochester Medical Center, USA, and Wang Long at Central South University, Changsha, China, investigated the role that estrogen receptor beta (ERβ) plays in BCa. They found that reducing ERβ levels made BCa cells less invasive. Further investigation revealed a way to block ERβ signaling, which made BCa tumors less likely to invade neighboring tissue in a mouse model. Understanding the ERβ signaling pathway may help to develop better treatments for BCa.

This study contributes to the existing literature on the influence of public subsidies on farmers' technical efficiency by highlighting the importance of separating persistent and transient inefficiency. Using data from a sample of French mixed (crop-livestock) farms, and relying on recent developments in stochastic frontier analysis, we find that public subsidies are positively associated with both persistent and transient technical inefficiency. The effect of public subsidies on persistent technical inefficiency suggests that they induce sluggish adjustments (restructuring) in farm management practices. [ABSTRACT FROM AUTHOR]

This article explores Jacques Derrida's writings on money, language, and justice. Derrida emphasizes the interconnectedness of these concepts and cautions against isolating money as a separate subject of study. The text also discusses the relationship between money and authenticity, as well as the role of the law in guaranteeing belief in money. It raises questions about the ethical and social implications of money and the choices individuals and societies make in relation to it. Additionally, the article explores the concepts of gift, solidarity, and justice, and suggests that Derrida's work can help address the challenges of contemporary capitalism and promote a more just society. [Extracted from the article]