Retrograde Versus Antegrade Nerve Sparing During Robot-assisted Radical Prostatectomy: Which Is Better for Achieving Early Functional Recovery?

Background

Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated.

Objective

To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes.

Design, setting, and participants

Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups.

Surgical procedure

RARP with antegrade NS (n = 172) or RARP with retrograde NS (n = 172).

Outcome measurements and statistical analysis

Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied.

Results and limitations

Positive margin rates were similar (11.1% vs 6.9%; p = 0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482–4.089; p = 0.001) at 3, 4.024 (95% CI, 2.171–7.457; p < 0.001) at 6, and 2.145 (95% CI, 1.019–4.514; p = 0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study.

Conclusions

In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.     

Laparoscopic Hepatic Posterior Sectionectomy: A Hand-assisted Approach

Background

Hepatic resection remains a challenging procedure in laparoscopy, requiring trained surgical teams and specialized centers.1 ^– 3 Operating on the posterior segments of the liver brings additional concerns, such as vascular control, right liver mobilization from the retroperitoneum and diaphragm, and a large transection area.1 ^, 3 ^– 6 Here we present a case of a hepatitis B-positive 42-year-old woman with a neoplastic nodule on the right posterior section of the noncirrhotic liver.

Methods

Pneumoperitoneum was made through a hand port, and three additional trocars were placed. Intrahepatic glissonian pedicle control was achieved after liver mobilization. Parenchymal transection was performed through the demarcation line between the anterior well vascularized and the posterior ischemic right segments of the liver. All surgical steps were performed with hand assistance.

Results

Operative time was 210 min, and estimated blood loss was 300 ml. Postoperative was uneventful. The patient was discharged on the fourth postoperative day. Histological evaluation confirmed the diagnosis of a well-differentiated hepatocellular carcinoma. The patient was free of disease after 18 months of follow-up.

Discussion

Our video shows a standardized operative strategy in which the hand assistance plays important role. Posterosuperior segments of the liver are still less often approached by laparoscopic surgery as a result of its limitations on visualization, mobilization, pedicle control, and parenchymal transection.1 ^, 3 ^, 6 Hand assistance helps solve these issues, making assisted resection easier than a purely laparoscopic approach and more advantageous over the open technique, providing the benefits of laparoscopy without compromising oncological safety.7     

The assessment of limb apraxia: Relationship between performances on single- and multiple-object tasks by left hemisphere damaged aphasic subjects

Two types of object manipulation tests, commonly advocated for the assessment of limb apraxia, were administered to 30 left hemisphere damaged aphasic (LHD) adults and 10 non-neurologically impaired control subjects. The tests were a multiple-object (MOT), requiring the manipulation of several related objects (e.g., lighting a candle when given a candle, a handle holder, and a match), and a single-object test (SOT) (e.g., lighting a match). Each of the subject's responses was assigned to one of six response categories: Standard (in which the response met all criteria for a faultless response) and five Nonstandard categories (Clumsy, Mislocation, Object Misuse, Perplexity, Omission). The results on comparing performances on the two tests showed that the SOT was “harder” than the MOT. Also, analyses of the relationship between MOT and SOT performances for the LHD subjects resulted in strong correlations between tests, loadings on the same two factors, and no evidence of double dissociations between the two tests for individual subjects. The two factors were interpreted to be a “conceptual/semantic” and a “motor execution” factor. The strong relationship and absence of double dissociations between response categories across the SOT and MOT suggest that both tasks are mediated by the same two neuropsychological processes. Clinical and theoretical implications of the findings are discussed.     

Characteristics of implant-CAD/CAM abutment connections of two different internal connection systems

Titanium or zirconium computer-aided design/computer-aided manufacturing abutments are now widely used for aesthetic implant treatments; however, information regarding microscopic structural differences that may influence the biological and mechanical outcomes of different implant systems is limited. Therefore, the characteristics of different connection systems were investigated. Optical microscopic observation and scanning electron microscopy showed different characteristics of two internal systems, namely the Astra Tech and the Replace Select system, and for different materials. The scanning electron microscopic observation showed for the Astra Tech that the implant-abutment interface seemed to be completely sealed for both titanium and zirconium abutments, both horizontally and sagittally; however, the first implant-abutment contact was below the fixture top, creating a microgap, and fixtures connected with titanium abutments showed significantly larger values (23·56μm±5·44 in width, and 168·78μm±30·39 in depth, P<0·001). For Replace Select, scanning electron microscopy in the sagittal direction showed that the sealing of titanium and zirconium abutments differed. The seal between the implant-titanium and implant-zirconium abutments seemed to be complete at the butt-joint interface; however, the displacement of the abutment in relation to the fixture in the lateral direction was evident for both abutments with no statistical differences (P>0·70), creating an inverted microgap. Thus, microscopy evaluation of two commonly used internal systems connected to titanium or zirconium abutments showed that the implant-abutment interface was perfectly sealed under no-loading conditions. However, an inverted microgap was seen in both systems, which may result in bacterial accumulation as well as alteration of stress distribution at the implant-abutment interface.     

Application of forensic anthropology to non-forensic issues: an experimental taphonomic approach to the study of human body decomposition in aerobic conditions

The knowledge of the decomposition process takes a progressively central role in cemetery management. In Europe there is an increase in constructing concrete modules that allow aerobic decomposition, which, theoretically, have advantages. By allowing the circulation of oxygen they will lead to a rapid decomposition, and, consequently, permit burial space rotation. This method also allows the burial of several corpses in small areas. In addition, it solves environmental issues. However, the ways in which the decomposition occurs under these conditions and the time required for skeletonization are still unknown. The aim of this study is to analyse the changes of the cadavers buried in aerobic module systems, realize the time necessary for skeletonization, and study solutions that might enable a faster decomposition. This experimental study utilized three aerobic module systems already used in Portuguese cemeteries and a prototype, with four pig carcasses as animal models. The evolution of the decomposition process was assessed weekly, over 147 days (2184 ADD). This study showed differences in the decomposition process between the four systems. The results allowed us to select the necessary characteristics for the construction of aerobic modules enabling faster decomposition.     

Reproducibility of the items on the Stroke Specific Quality of Life questionnaire that evaluate the participation component of the International Classification of Functioning,Disability and Health

Purpose: To evaluate the reproducibility of the Stroke Specific Quality of Life (SS-QOL) items that address the participation component of the International Classification of Functioning, Disability and Health (ICF) and analyse the correlation between the subscore of these 26 items and the total SS-QOL score.

Methods: Seventy-five stroke survivors participated in this study. Reproducibility was evaluated using the intraclass correlation coefficient (ICC_2,1), standard error of measurement (SEM), minimum detectable change (MDC) and the Bland–Altman plot. The correlation between the subscore of the 26 items and the total SS-QOL score was analysed using Spearman’s correlation coefficients (rho) and simple linear regression. An alpha risk?≤?0.05 was considered for all analyses.

Results: The SS-QOL items that address the participation component of the ICF demonstrated excellent reliability (intra-rater ICC_2,1?=?0.96; inter-rater ICC_2,1?=?0.95). The SEM and MDC were adequate. The Bland–Altman plot demonstrated satisfactory agreement. A significant and strong correlation (rho?=?0.83) was found between the 26 SS-QOL items that address participation and the total SS-QOL score. Moreover, the evaluation of participation was found to explain 73% of the evaluation of health-related quality of life.

Conclusion: The 26 SS-QOL items that address the participation component of the ICF demonstrated adequate reproducibility. Thus, participation, which represents the social aspects of functionality, can be adequately evaluated with these items.

• Implications for Rehabilitation

• The 26 Stroke Specific Quality of Life items that address participation proved to be reproducible for the analysis of social participation following a stroke.

• The findings can lead to a better understanding of the social participation of individuals with chronic hemiparesis and assist in the establishment of adequate treatment for such individuals.

• The rehabilitation process can be directed towards more specific goals focused on the patient expectations, thereby contributing to greater humanization and effectiveness of treatment to improve social participation following a stroke.