Explore the vast range of titles available.

Background In humans, sperm DNA fragmentation rates have been correlated with sperm viability rates. Reduced sperm viability is associated with high sperm DNA fragmentation, while conversely high sperm viability is associated with low rates of sperm DNA fragmentation. Both elevated DNA fragmentation rates and poor viability are correlated with impaired male fertility, with a DNA fragmentation rate of > 30% indicating subfertility. We postulated that in some men, the sperm viability assay could predict the sperm DNA fragmentation rates. This in turn could reduce the need for sperm DNA fragmentation assay testing, simplifying the infertility investigation and saving money for infertile couples. Methods All men having semen analyses with both viability and DNA fragmentation testing were identified via a prospectively collected database. Viability was measured by eosin-nigrosin assay. DNA fragmentation was measured using the sperm chromosome structure assay. The relationship between DNA fragmentation and viability was assessed using Pearson’s correlation coefficient. Results From 2008-2013, 3049 semen analyses had both viability and DNA fragmentation testing. A strong inverse relationship was seen between sperm viability and DNA fragmentation rates, with r = -0.83. If viability was ≤ 50% (n = 301) then DNA fragmentation was ≥ 30% for 95% of the samples. If viability was ≥ 75% (n = 1736), then the DNA fragmentation was ≤ 30% for 95% of the patients. Sperm viability correlates strongly with DNA fragmentation rates. Conclusions In men with high levels of sperm viability ≥ 75%, or low levels of sperm viability ≤ 30%, DFI testing may be not be routinely necessary. Given that DNA fragmentation testing is substantially more expensive than vitality testing, this may represent a valuable cost-saving measure for couples undergoing a fertility evaluation.

Robot-assisted laparoscopic radical prostatectomy (RALP) relies heavily on the bedside assistant (BA). Currently, the relationship between BA experience and surgical outcomes in robotic surgery is not clear. We examined whether bedside assistant experience can significantly affect positive margin rate and peri-operative outcomes for RALP for surgeons within their learning curve. A retrospective cohort study of a single surgeon’s peri-operative outcomes during RALP was examined and compared with and without an experienced bedside assistant. Patient demographic data and peri-operative data, margin rate, and length of stay (LOS), were collected and analyzed. Univariate and multivariable analyses were performed to determine if expert BA was a predictor of post-operative outcomes. In total, 170 consecutive cases over three years were analyzed. 111 (65%) were performed without an expert BA. The two groups were not significantly different with regards patient demographics ( p  > 0.05). On univariate analysis, having an expert BA was associated with a significantly lower LOS (31 h ± 21 vs. 42 h ± 26, p  = 0.004), EBL (296 ml ± 180 vs. 441 ml ± 305, p  < 0.0001) and positive margin rate (20% vs. 37%, p  = 0.03). Other surgical outcomes were comparable between groups. On multivariable analysis, expert BA remained a predictor of, EBL (B stat = − 146, 95% CI − 240 to − 52, p  = 0.003) and positive margin rate (OR 0.4, 95% CI 0.2–0.96, p  = 0.04). Our results demonstrate that the use of an expert BA may result in improved patient outcomes early in the learning curve of RALP, most notably, positive margin rate and estimated blood loss.

Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80 g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution’s initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4 years, with mean prostate volume of 104 ± 11 g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98 mL and operative time was 172 ± 19 min. Mean catheter time was 1.9 ± 1.8 days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.

BackgroundUp to 20% of medical students are unable to reach competency in laparoscopic surgery. It is unknown whether these difficulties arise from heterogeneity in neurological functioning across individuals. We sought to examine the differences in neurological functioning during laparoscopic tasks between high- and low-performing medical students using functional magnetic resonance imaging (fMRI).MethodsThis prospective cohort study enrolled North American medical students who were within the top 20% and bottom 20% of laparoscopic performers from a previous study. Brain activation was recorded using fMRI while participants performed peg-pointing, intracorporeal knot tying (IKT), and the Pictorial Surface Orientation (PicSOr) test. Brain activation maps were created and areas of activation were compared between groups.ResultsIn total, 9/12 high and 9/13 low performers completed the study. High performers completed IKT faster and made more successful knot ties than low performers [standing: 23.5 (5.0) sec vs. 37.6 (18.4) sec, p = 0.03; supine: 23.2 (2.5) sec vs. 72.7 (62.8) sec, p = 0.02; number of successful ties supine, 3 ties vs. 1 tie, p = 0.01]. Low performers showed more brain activation than high performers in the peg-pointing task (q < 0.01), with no activation differences in the IKT task. There were no behavioral differences in the PiCSOr task.ConclusionsThis study is the first to show differences between low and high performers of laparoscopic tasks at the brain level. This pilot study has shown the feasibility of using fMRI to examine laparoscopic surgical skills. Future studies are needed for further exploration of our initial findings.

We use machine learning to evaluate surgical skill from videos during the tumor resection and renography steps of a robotic assisted partial nephrectomy (RAPN). This expands previous work using synthetic tissue to include actual surgeries. We investigate cascaded neural networks for predicting surgical proficiency scores (OSATS and GEARS) from RAPN videos recorded from the DaVinci system. The semantic segmentation task generates a mask and tracks the various surgical instruments. The movements from the instruments found via semantic segmentation are processed by a scoring network that regresses (predicts) GEARS and OSATS scoring for each subcategory. Overall, the model performs well for many subcategories such as force sensitivity and knowledge of instruments of GEARS and OSATS scoring, but can suffer from false positives and negatives that would not be expected of human raters. This is mainly attributed to limited training data variability and sparsity.

Robotic-assisted simple prostatectomy (RASP) has proven to be an effective minimally invasive option for benign prostatic enlargement (BPE) in recent years. Single-site surgery is theorized to reduce post-operative pain beyond traditional minimally invasive approaches. We sought to assess whether use of a single-port robotic platform decreases post-operative opioid use in patients undergoing robotic-assisted simple prostatectomy (RASP). A retrospective review was performed of all patients undergoing RASP our institution from November 2017 to July 2019. Demographic, intraoperative, and post-operative data, including morphine equivalent (ME) use, were collected. Patients were stratified by robotic platform utilized. Propensity score matching using nearest neighbor method was performed using prostate volume, Charlson comorbidity index (CCI), and post-op ketorolac use in 4:1 fashion. Chi-squared analysis and Kruskal–Wallis analyses were utilized. Two-hundred-and-seven men underwent RASP. After matching, 80 patients (64 multi-port, 16 single-port) were included in the analysis. Groups were comparable for age, body mass index, CCI, prostate volume, prior opioid use, and use of scheduled ketorolac post op. The single-port approach was associated with a reduction in MEs once admitted to the floor (5 vs. 11 mg, p  = 0.025) and an increase in the proportion of patients who did not require any narcotics post-operatively (44 vs. 19%, p  = 0.036). In a propensity matched cohort of patients undergoing RASP at a single institution, use of the single-port robotic system conferred a significant decrease in post-operative narcotic use by approximately 50%.

We seek to understand if an automated algorithm can replace human scoring of surgical trainees performing the urethrovesical anastomosis in radical prostatectomy with synthetic tissue. Specifically, we investigate neural networks for predicting the surgical proficiency score (GEARS score) from video clips. We evaluate videos of surgeons performing the urethral anastomosis using synthetic tissue. The algorithm tracks surgical instrument locations from video, saving the positions of key points on the instruments over time. These positional features are used to train a multi-task convolutional network to infer each sub-category of the GEARS score to determine the proficiency level of trainees. Experimental results demonstrate that the proposed method achieves good performance with scores matching manual inspection in 86.1% of all GEARS sub-categories. Furthermore, the model can detect the difference between proficiency (novice to expert) in 83.3% of videos. Evaluation of GEARS sub-categories with artificial neural networks is possible for novice and intermediate surgeons, but additional research is needed to understand if expert surgeons can be evaluated with a similar automated system.

Introduction:There has been increasing interest in assessing the surgical performance of practicing surgeons. There is a growing body of literature linking a surgeon’s technical skill to short-term post-operative complications. However, little research has been performed examining technical skill and patient safety, and no research has examined the relationship between technical performance and hospital cost. The primary purpose of this thesis is to determine the relationship between direct, 30-day hospital costs and surgeon technical skill in open and robotic partial nephrectomy.Methods:We performed four studies: a systematic review examining the literature on intraoperative adverse events and costs, a prospective, multicenter, multi-surgeon study examining the relationship between direct, 30-day hospital costs and surgeon technical skill, and a prospective, multicenter, multi-surgeon study comparing the rates of intraoperative events between open and robotic partial nephrectomy. Finally, we performed a cost utility analysis to compare the cost effectiveness of open partial nephrectomy to robotic partial nephrectomy.Results:Four research studies were completed. Our systematic review found that while the overall quality of the current literature was poor, intraoperative events increase the cost of abdominal surgery. For our surgical safety study, open partial nephrectomy has a greater number of severe intraoperative events than robotic partial nephrectomy. When comparing the costs between surgeons of differing skill levels, surgeons with higher levels of technical skill cost less than surgeons with lower levels of skill. Finally, at a Willingness to Pay (WTP) of$200,000/QALY, open partial nephrectomy is the most cost effective option, although robotic partial nephrectomy becomes cost effective when the fixed robotic costs are below $ 3,330 per case.Conclusion:We are the first to study the relationship between surgeon performance and short-term hospital costs. While future studies need to confirm our findings, our results highlight the possibility of financial benefit from improving surgeon performance. Furthermore, we conclude that the robotic platform may improve intraoperative patient safety and intraoperative event assessment may be useful in providing individualized feedback.

Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution’s robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1 cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3–0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6 years and body mass index of 20.3 ± 3.3 g underwent the procedure. Mean operative time was 143 ± 20 min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3 cm. Median day of discharge was 1.5 days (range 1–3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed.