Home practice for robotic surgery: a randomized controlled trial of a low-cost simulation model.

Pre-operative simulated practice allows trainees to learn robotic surgery outside the operating room without risking patient safety. While simulation practice has shown efficacy, simulators are expensive and frequently inaccessible. Cruff (J Surg Educ 78(2): 379-381, 2021) described a low-cost simulation model to learn hand movements for robotic surgery. Our study evaluates whether practice with low-cost home simulation models can improve trainee performance on robotic surgery simulators. Home simulation kits were adapted from those described by Cruff (J Surg Educ 78(2): 379-381, 2021). Hand controllers were modified to mimic the master tool manipulators (MTMs) on the da Vinci Skills Simulator (dVSS). Medical students completed two da Vinci exercises: Sea Spikes 1 (SS1) and Big Dipper Needle Driving (BDND). They were subsequently assigned to either receive a home simulation kit or not. Students returned two weeks later and repeated SS1 and BDND. Overall score, economy of motion, time to completion, and penalty subtotal were collected, and analyses of covariance were performed. Semi-structured interviews assessed student perceptions of the robotic simulation experience. Thirty-three medical students entered the study. Twenty-nine completed both sessions. The difference in score improvement between the experimental and control groups was not significant. In interviews, students provided suggestions to increase fidelity and usefulness of low-cost robotic home simulation. Low-cost home simulation models did not improve student performance on dVSS after two weeks of at-home practice. Interview data highlighted areas to focus future simulation efforts. Ongoing work is necessary to develop low-cost solutions to facilitate practice for robotic surgery and foster more inclusive and accessible surgical education.

A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause.

BACKGROUND: Despite some prospective case series showing effectiveness of vaginal laser to treat genitourinary syndrome of menopause (GSM), there is a paucity of placebo-controlled level one evidence. AIM: To assess the effect of fractional carbon dioxide (CO2) laser therapy to treat GSM against a sham comparator. METHODS: We conducted a parallel, randomized, double-blind, sham-controlled trial to compare menopausal women treated with fractional CO2 laser against sham treatment for improvement in GSM-related dyspareunia. Three treatments were given 6 weeks apart, and participants attended a 6-month visit from study start for primary (proportion improved) and secondary (vaginal health index, VHI; visual analogue scale, VAS; modified global assessment, PGI-I; Female Sexual Function Index, FSFI; Day-to-Day Impact of Vaginal Aging, DIVA; Urinary Distress Inventory short-form, UDI-6) assessments. OUTCOMES: The primary endpoint was a 2-stage improvement in GSM-related dyspareunia from baseline to 6 months determined by a severity scale, and the proportion of subjects who achieved this were compared between groups. RESULTS: Thirty participants were randomized to laser (n = 14) or sham (n = 16). In the treatment arm, 13 attended all treatments, and 1 attended at least 2 while in the sham arm, 14 attended all treatments, and 2 attended at least 2 treatments. Twelve (86%) in the treatment arm and 16 (100%) in the sham arm attended the 6-month visit. There were no differences in the proportion improved between treatments and controls (64% vs. 67%, respectively, P = 1.000). Both arms showed significant within-group improvements based on VHI and VAS, but not between groups. Similar findings were observed on sexual impact questionnaires with improvements within both groups from baseline to 6 months but not by median differences between the groups at 6 months. There were no adverse events in either of the arms. CLINICAL IMPLICATIONS: Further well-powered research is needed to determine efficacy of fractional CO2 laser for the treatment of GSM, especially in light of a potential placebo effect. STRENGTHS & LIMITATIONS: We present a sham-controlled double-blinded randomized trial using validated tools; the main limitation included an underpowered proportion of sexually active participants for the primary outcome. CONCLUSION: This study was underpowered to draw conclusions regarding the efficacy of fractional CO2 laser therapy in the treatment of GSM. We did observe improvements in the sham-arm to suggest a possible placebo contribution. Further well-powered level one research is needed to demonstrate the therapeutic effect of this novel modality. Cruff J, Khandwala S, A Double-Blind Randomized Sham-Controlled Trial to Evaluate the Efficacy of Fractional Carbon Dioxide Laser Therapy on Genitourinary Syndrome of Menopause. J Sex Med 2021;18:761-769.

Retrospective Analysis of Sexual Function After Transvaginal Mesh Surgery.

INTRODUCTION: Despite ample research regarding the impact of reconstructive surgery on anatomic/functional outcomes of pelvic organ prolapse (POP), including incidence of dyspareunia, evidence regarding sexual outcomes is equivocal. AIM: To assess changes in sexual function in women followed up for at least 12 months after transvaginal mesh surgery for POP. METHODS: We conducted a retrospective review of women who underwent surgery for POP using different mesh products between 2008 and 2019. Baseline demographics were compiled along with intraoperative and postoperative information. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) was used to assess sexual function. MAIN OUTCOME MEASURES: Women sexually active before and after surgery were assessed to determine changes in overall and question-specific PISQ-12 responses and potential factors to explain sexual function after surgery. RESULTS: 622 women underwent surgery using mesh at our center. 360 (58%) attended at least one visit at a median of 12 months (IQR 11-23 months), with 113 (31%) sexually active at baseline and 247 (69%) sexually inactive. 97 had complete PISQ-12 responses before and after surgery. There was an overall improvement in the median PISQ-12 scores of 2 points (P < .001); improvements persisted when scores were stratified by various factors. Specific improvements were noted in climax (P = .046) and orgasm intensity (P = .002), fear (P < .001) or actual incontinence during intercourse (P = .004), avoidance of intercourse due to prolapse (P < .001), and negative emotions (P < .001). There was a slight positive effect of the baseline PISQ-12 score on the postoperative PISQ-12 score (regression coefficient 0.24, 95% CI: 0.09-0.39), and a stronger negative effect of having a concomitant anal sphincteroplasty (-4.84, 95% CI: -8.42 to -1.25). Preoperative prolapse stage was not associated with postoperative sexual outcomes. There was a weak negative association between the postoperative PISQ-12 and Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) scores [rs(95) = -0.27, P = .008] and a moderate negative association between postoperative PISQ-12 and total Pelvic Floor Distress Inventory short form [rs(94) = -0.42, P < .001]. CONCLUSION: Transvaginal mesh surgery appears to positively impact sexual function, and improvements were independent of mesh or baseline prolapse severity. Khandwala S, Cruff J, Williams C. Retrospective Analysis of Sexual Function After Transvaginal Mesh Surgery. Sex Med 2021;9:100281.

Single-incision Midurethral Sling by the Dynamic Intraoperative Standing Sling Technique as an Office-based Procedure: A Pilot Study.

OBJECTIVES: To assess the safety, feasibility, and short-term success of placing Solyx (Boston Scientific, Marlborough, MA) single-incision midurethral sling (SIMUS) using the Dynamic Intraoperative Standing Sling Technique (DISST) in an office setting under local anesthesia. METHODS: The safety and efficacy of the in-office Solyx DISST procedure for treatment of stress urinary incontinence was assessed 6 months from the procedure. Improvement in stress urinary incontinence was measured using validated questionnaires (Medical, Epidemiologic, and Social Aspects of Aging, MESA; Incontinence Impact Questionnaire-7, IIQ-7; Pelvic Organ Prolapse/Urinary Incontinence Sexual Function, PISQ-12) and by a negative standing provocative stress test. Postoperative complications were documented along with subjective pain diaries, return to work/activities, and overall satisfaction. RESULTS: From July 2019 through February 2020, 20 subjects underwent in-office Solyx procedure by the DISST technique. Six of the 20 (30%) subjects required intraoperative sling adjustments. There were no complications as related to the office-based procedure. Participants reported a favorable intraoperative experience. Subjects had excellent postoperative pain control and early return to work and normal activities. At 6 months, all 20 subjects had negative standing provocative stress tests, showed statistically significant improvements on MESA, IIQ-7, and PISQ-12, and reported high satisfaction and acceptance for the procedure and outcomes. There were no late (>6 weeks) complications associated with the Solyx procedure. CONCLUSIONS: It appears safe and feasible to perform Solyx SIMUS by the DISST method in the office. Subjects remained dry and reported excellent improvement in symptoms and quality of life 6 months from surgery.

Robotic Surgical Training at Home: A Low-Fidelity Simulation Method.

OBJECTIVE: Laparoscopic box simulators provide surgical residents a cost-effective and accessible learning tool to practice basic laparoscopic skills. Despite effective, high-fidelity simulators used in robotic surgery training, a similar low-fidelity alternative simulation method is not available. The objective of this report and accompanying video is to introduce a low-fidelity method to help those new to robotic-assisted surgery learn fundamental skills even before sitting at the console. METHOD: Using 2 fine-point metal tweezers with Velco loops for finger slots, I developed a user-friendly way to practice basic needle handling and intracorporeal knot tying activities similar to those encountered on a high-fidelity robotic simulator. These simple tools mimic the controllers at the actual robot console. EXPERIENCE: This teaching tool is meant to help surgical trainees and those new to robotic surgery develop the initial dexterity and economy of motion for performing basic tasks. I have greatly improved my own surgical confidence and experience anecdotally using these tools before I sat for actual cases. I hope a motivated trainee may discover the same benefit. CONCLUSIONS: A low-fidelity simulation method may enhance a learner's initial proficiency in robotic-assisted surgery, but future performance studies using this method will be needed.

Prospective analysis of transvaginal mesh hysteropexy in the treatment of uterine prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the efficacy of using transvaginal mesh to correct uterine prolapse by hysteropexy. METHODS: This was a single-center, prospective study of 40 subjects with bothersome uterine prolapse. Inclusion criteria were bothersome perception of a vaginal bulge on Pelvic Floor Distress Inventory short form (PFDI-20) and having a Pelvic Organ Prolapse Quantification System (POP-Q) point C of -2 or worse. Exclusionary criteria included inability to consent, history of pelvic malignancies, or any prior prolapse repair. Eligible subjects were treated with transvaginal mesh hysteropexy between March 2016 and July 2018 for a primary outcome of composite success, which was defined by a POP-Q point C value of -2 or higher, PFDI-20 question 3 indicating no bothersome perception of prolapse, and no retreatment. Secondary outcomes included responses to condition-specific and quality-of-life questionnaires, satisfaction/regret, and complications. RESULTS: Transvaginal mesh hysteropexy was performed in 40 subjects. The majority (68%) had advanced stage (III/IV) uterine prolapse. At a median follow-up of 12 months, there was an 84% composite success, and considering only anatomic criteria (POP-Q point C < -1), there was a 92% success. No subject required reintervention for recurrent or persistent uterine prolapse. There were no cases of mesh exposures. In terms of safety, one subject required a blood transfusion for symptomatic anemia (Clavien-Dindo grade II), and one subject reported de novo dyspareunia from a perineal band that was released in office at 6 months (grade IIIa), but otherwise there were no serious immediate or late complications. There were significant improvements in both condition-specific and quality-of-life assessments from baseline. Subject satisfaction and acceptance for the procedure were high. CONCLUSIONS: In this single-center case series of 40 women with bothersome uterovaginal prolapse, transvaginal mesh hysteropexy appears safe and effective for correcting advanced stage uterine prolapse at the short term. A future multicenter controlled trial would be needed to determine efficacy against native tissue repair.

The Role of Yoga in the Management of Bladder Pain Syndrome: A Single-Arm Pilot Study.

BACKGROUND: Bladder pain syndrome (BPS) is a devastating urologic condition characterized by irritative bladder symptoms, pelvic pain, and dyspareunia. First-line treatment includes dietary, self-care and behavioral modifications. The ancient practice of yoga is well suited to treat BPS, but evidence is lacking on its use. AIMS: To investigate the feasibility and efficacy of an integrated yoga module on BPS outcomes as measured by self-reported questionnaires from baseline to 3 months after therapy. METHODS AND MATERIALS: This was a prospective single-arm study of 8 patients who underwent 3 months of integrated yoga therapy. The treatment module was performed 3 to 4 times weekly at home with 1 session performed weekly in-office during the first month to ensure proper performance of postures. Patients completed questionnaires (Pelvic Pain and Urgency/Frequency Patient Symptom Scale [PUF], Pelvic Floor Impact Questionnaire - short form 7 [PFIQ-7], Short Form 36 questionnaire [SF-36], Pittsburgh Sleep Quality Index [PSQI]) at baseline and 3 months, including Patient Global Impression of Improvement (PGI-I) at the 3-month follow-up visit. Voiding diaries were also requested at baseline and at the 3-month assessment. RESULTS: There was a trend toward improvement regarding patients' responses to all questionnaires 3 months after yoga therapy, with the only statistically significant improvements noted in social function and pain components of the SF-36. There were no significant changes noted on the voiding diaries except a non-statistically significant trend toward increased voided volumes. Patients rated their experiences with yoga therapy positively. CONCLUSIONS: Yoga therapy for BPS showed evidence of benefit for improving bothersome bladder symptoms, pain and voiding. A randomized controlled trial will follow to investigate the efficacy of this yoga module against a control group.

Adiponectin protects against hyperoxic lung injury and vascular leak.

Adiponectin (Ad), an adipokine exclusively secreted by the adipose tissue, has emerged as a paracrine metabolic regulator as well as a protectant against oxidative stress. Pharmacological approaches of protecting against clinical hyperoxic lung injury during oxygen therapy/treatment are limited. We have previously reported that Ad inhibits the NADPH oxidase-catalyzed formation of superoxide from molecular oxygen in human neutrophils. Based on this premise, we conducted studies to determine whether (i) exogenous Ad would protect against the hyperoxia-induced barrier dysfunction in the lung endothelial cells (ECs) in vitro, and (ii) endogenously synthesized Ad would protect against hyperoxic lung injury in wild-type (WT) and Ad-overexpressing transgenic (AdTg) mice in vivo. The results demonstrated that exogenous Ad protected against the hyperoxia-induced oxidative stress, loss of glutathione (GSH), cytoskeletal reorganization, barrier dysfunction, and leak in the lung ECs in vitro. Furthermore, the hyperoxia-induced lung injury, vascular leak, and lipid peroxidation were significantly attenuated in AdTg mice in vivo. Also, AdTg mice exhibited elevated levels of total thiols and GSH in the lungs as compared with WT mice. For the first time, our studies demonstrated that Ad protected against the hyperoxia-induced lung damage apparently through attenuation of oxidative stress and modulation of thiol-redox status.

Lipoxygenase-catalyzed phospholipid peroxidation: preparation, purification, and characterization of phosphatidylinositol peroxides.

The importance of understanding the mechanisms of modulation of cellular signaling cascades by the peroxidized membrane phospholipids (PLs) is well recognized. The enzyme-catalyzed peroxidation of PLs, as opposed to their oxidation by air and metal catalysis, is well controlled and rapid and yields well-defined PL peroxides which are highly desirable for biological studies. Therefore, here, we chose bovine liver phosphatidylinositol (PI), a crucial membrane PL which acts as the substrate for phospholipase C in cellular signal transduction, as a model membrane PL. We successfully generated the PI peroxides with soybean type-I lipoxygenase (LOX) in the presence of deoxycholate, which facilitates the LOX-mediated peroxidation of the polyunsaturated fatty acids esterified to the PL. The LOX-peroxidized PI, after enzymatic catalysis, was separated from the unoxidized PI in the reaction mixture by normal-phase, high-performance liquid chromatography (HPLC). The extent of LOX-mediated peroxidation of PI following HPLC purification was established by the analysis of lipid phosphorus, conjugated dienes by UV spectrophotometry, peroxides, and loss of fatty acids by gas chromatography. This study established the optimal conditions yielding approximately 46% of peroxidized PI from 300 microg of neat bovine liver PI that was peroxidized by soybean type-I LOX (50 microg) for 30 min in borate buffer (0.2 M, pH 9.0) containing 10 mM deoxycholate.

Redox-active antioxidant modulation of lipid signaling in vascular endothelial cells: vitamin C induces activation of phospholipase D through phospholipase A2, lipoxygenase, and cyclooxygenase.

We have earlier reported that the redox-active antioxidant, vitamin C (ascorbic acid), activates the lipid signaling enzyme, phospholipase D (PLD), at pharmacological doses (mM) in the bovine lung microvascular endothelial cells (BLMVECs). However, the activation of phospholipase A(2) (PLA(2)), another signaling phospholipase, and the modulation of PLD activation by PLA(2) in the ECs treated with vitamin C at pharmacological doses have not been reported to date. Therefore, this study aimed at the regulation of PLD activation by PLA(2) in the cultured BLMVECs exposed to vitamin C at pharmacological concentrations. The results revealed that vitamin C (3-10 mM) significantly activated PLA(2) starting at 30 min; however, the activation of PLD resulted only at 120 min of treatment of cells under identical conditions. Further studies were conducted utilizing specific pharmacological agents to understand the mechanism(s) of activation of PLA(2) and PLD in BLMVECs treated with vitamin C (5 mM) for 120 min. Antioxidants, calcium chelators, iron chelators, and PLA(2) inhibitors offered attenuation of the vitamin C-induced activation of both PLA(2) and PLD in the cells. Vitamin C was also observed to significantly induce the formation and release of the cyclooxygenase (COX)- and lipoxygenase (LOX)-catalyzed arachidonic acid (AA) metabolites and to activate the AA LOX in BLMVECs. The inhibitors of PLA(2), COX, and LOX were observed to effectively and significantly attenuate the vitamin C-induced PLD activation in BLMVECs. For the first time, the results of the present study revealed that the vitamin C-induced activation of PLD in vascular ECs was regulated by the upstream activation of PLA(2), COX, and LOX through the formation of AA metabolites involving oxidative stress, calcium, and iron.