Conditioned Canine Cadavers for Near-Natural Interprofessional Veterinary and Human Surgery Training.

Both medical and veterinary students find that the use of cadavers is critical to learning anatomical structures and surgical techniques. The use of human cadavers and the resulting user emotions are driven by serious ethical issues that are currently much less pronounced in veterinary education. Ethically sourced canine cadavers, thus, are more readily available. Aesthetics such as odor and visual appearance, though, influence both learner and educator motivation. We have investigated a way of delaying cadaver decomposition by post-mortem in situ, chemical-free, gastrointestinal lavage. We are convinced that canine cadavers, conditioned as described here, will improve the outcome of cadaver-based surgical skills training by facilitating preparation, reducing the number of required cadavers, postponing decomposition, improving the surgeon's haptic-tactile response to organ and tissue handling and suturing, and, possibly most importantly, increasing learners' and educators' focus due to the significantly improved aesthetics. We hypothesize that skill transfer for medical students and doctors, because of the similar abdominal anatomy, may be easier when training with conditioned canine cadavers as compared to artificial simulators or pigs in vivo.

Prognostic value of contralateral suppression on kidney function after surgery in patients with primary aldosteronism.

BACKGROUND AND OBJECTIVE: Adrenalectomy for primary aldosteronism (PA) has been associated with decreased kidney function after surgery. It has been proposed that elimination of excess aldosterone unmasks an underlying failure of the kidney function. Contralateral suppression (CLS) is considered a marker of aldosterone excess and disease severity, and the purpose of this study was to assess the hypothesis that CLS would predict change in kidney function after adrenalectomy in patients with PA. DESIGN AND PATIENTS: Patients with PA referred for adrenal venous sampling (AVS) between May 2011 and August 2021 and who were subsequently offered surgical or medical treatment were eligible for the current study. RESULTS: A total of 138 patients were included and after AVS 85/138 (61.6%) underwent adrenalectomy while 53/138 (38.4%) were treated with MR-antagonists. In surgically treated patients the estimated glomerular filtration rate (eGFR) was reduced by 11.5 (SD: 18.5) compared to a reduction of 5.9 (SD: 11.5) in medically treated patients (p = .04). Among surgically treated patients, 59/85 (69.4%) were classified as having CLS. After adrenalectomy, patients with CLS had a mean reduction in eGFR of 17.5 (SD: 17.6) compared to an increase of 1.8 (SD: 12.8) in patients without CLS (p < .001). The association between CLS and change in kidney function remained unchanged in multivariate analysis. Post-surgery, 16/59 (27.1%) patients with CLS developed hyperkalemia compared to 2/26 (7.7%) in patients without CLS (p = .04). CONCLUSION: This retrospective study found that CLS was a strong and independent predictor of a marked reduction of eGFR and an increased risk of hyperkalemia after adrenalectomy in patients with PA.

Identifying curriculum content for a cross-specialty robotic-assisted surgery training program: a Delphi study.

BACKGROUND: Robotic-assisted surgery is increasing and there is a need for a structured and evidence-based curriculum to learn basic robotic competencies. Relevant training tasks, eligible trainees, realistic learning goals, and suitable training methods must be identified. We sought to develop a common curriculum that can ensure basic competencies across specialties. METHODS: Two robotic surgeons from all departments in Denmark conducting robotic-assisted surgery within gynecology, urology, and gastrointestinal surgery, were invited to participate in a three-round Delphi study to identify learning goals and rank them according to relevance for a basic curriculum. An additional survey was conducted after the Delphi rounds on what training methods were considered best for each learning goal and who (console surgeon/patient-side assistant) should master each learning goal. RESULTS: Fifty-six robotic surgeons participated and the response rates were 86%, 89%, and 77%, for rounds 1, 2 and 3, respectively. The Delphi study identified 40 potential learning goals, of which 29 were ranked as essential, e.g., Understand the link between arm placement and freedom of movement or Be able to perform emergency un-docking. In the additional survey, the response rate was 70%. Twenty-two (55%) of the identified learning goals were found relevant for the patient-side assistant and twenty-four (60%) were linked to a specific suitable learning method with > 75% agreement. CONCLUSIONS: Our findings can help training centers plan their training programs concerning educational content and methods for training/learning. Furthermore, patient-side assistants should also receive basic skills training in robotic surgery.

Validation of a Novel Simulation-Based Test in Robot-Assisted Radical Prostatectomy.

Purpose: To investigate validity evidence for a simulator-based test in robot-assisted radical prostatectomy (RARP). Materials and Methods: The test consisted of three modules on the RobotiX Mentor VR-simulator: Bladder Neck Dissection, Neurovascular Bundle Dissection, and Ureterovesical Anastomosis. Validity evidence was investigated by using Messick's framework by including doctors with different RARP experience: novices (who had assisted for RARP), intermediates (robotic surgeons, but not RARP surgeons), or experienced (RARP surgeons). The simulator metrics were analyzed, and Cronbach's alpha and generalizability theory were used to explore reliability. Intergroup comparisons were done with mixed-model, repeated measurement analysis of variance and the correlation between the number of robotic procedures and the mean test score were examined. A pass/fail score was established by using the contrasting groups' method. Results: Ten novices, 11 intermediates, and 6 experienced RARP surgeons were included. Six metrics could discriminate between groups and showed acceptable internal consistency reliability, Cronbach's alpha = 0.49, p < 0.001. Test-retest reliability was 0.75, 0.85, and 0.90 for one, two, and three repetitions of tests, respectively. Six metrics were combined into a simulator score that could discriminate between all three groups, p = 0.002, p < 0.001, and p = 0.029 for novices vs intermediates, novices vs experienced, and intermediates vs experienced, respectively. Total number of robotic operations and the mean score of the three repetitions were significantly correlated, Pearson's r = 0.74, p < 0.001. Conclusion: This study provides validity evidence for a simulator-based test in RARP. We determined a pass/fail level that can be used to ensure competency before proceeding to supervised clinical training.

Design and validation of a cross-specialty simulation-based training course in basic robotic surgical skills.

BACKGROUND: The aim of this study was to design and validate a cross-specialty basic robotic surgical skills training program on the RobotiX Mentor virtual reality simulator. METHODS: A Delphi panel reached consensus on six modules to include in the training program. Validity evidence was collected according to Messick's framework with three performances in each simulator module by 11 experienced robotic surgeons and 11 residents without robotic surgical experience. RESULTS: For five of the six modules, a compound metrics-based score could significantly discriminate between the performances of novices and experienced robotic surgeons. Pass/fail levels were established, resulting in very few novices passing in their first attempt. CONCLUSIONS: This validated course can be used for structured simulation-based basic robotic surgical skills training within a mastery learning framework where the individual trainee can practice each module until they achieve proficiency and can continue training on other modalities and more specific to their specialty.

Laparoscopic and robotic nephroureterectomy: does lymphadenectomy have an impact on the clinical outcome?

PURPOSE: To evaluate the effect of lymphadenectomy (LND) in conjunction with nephroureterectomy on cancer-specific mortality (CSM) and overall survival (OS) for patients with muscle-invasive UTUC. METHODS: A retrospective, multicenter study of patients with UTUC, clinical stage N0M0, who underwent nephroureterectomy between January 2008 and December 2014 was conducted. Outcome measures were OS and CSM. RESULTS: In total, 298 patients underwent robot-assisted or laparoscopic radical nephroureterectomy with a final histological diagnosis of UTUC. LND was performed in 46 (15.4%). One hundred and seventy-two patients (62%) had non-muscle-invasive disease (NMID); 105 patients (38%) had muscle-invasive disease (MID). Median time of follow-up was 43.5 months (95% CI 36.0-47.2). For patients with MID, the 5-year cumulative incidence of all-cause mortality and CSM was 73.5% (95% CI 60.4-86.6) and 52.4% (95% CI 38.9-65.9), respectively (p < 0.0001). There was no significant difference in OS between patients with N1 and patients with N0 disease (p = 0.53). The 5-year OS rates were 30.5% (95% CI 6.6-54.4) and 25.7% (95% CI 10.9-40.5), respectively. This study is limited by its retrospective nature. There may also have been bias in the selection of patients undergoing LND. CONCLUSIONS: Five-year OS and CSM are comparable between patients with N1 and N0 MID. This evidence may support the use of the LND procedure in patients with muscle-invasive UTUC.

[Adrenalectomy in Denmark 2002-2006]. / Adrenalektomi i Danmark 2002-2006.

INTRODUCTION: Laparoscopic adrenalectomy is replacing open adrenalectomy. The advantages are reduced mortality and morbidity, and shorter postoperative hospitalisation. The organization and short-term outcomes of adrenalectomy in Denmark are largely unknown. MATERIAL AND METHODS: Extraction, review, and analysis of data from the National Patient Register and discharge notes from 2002-2006. RESULTS: A total of 297 adrenalectomies, of which 161 were laparoscopic, were identified. Discharge notes were reviewed in 221 of these cases (2002-2005). All except three were performed in a university hospital setting. The laparoscopic to open conversion rate was 7.6%, mortality 1%, and complication rates for open/laparoscopic adrenalectomy 25%/16%. The mean postoperative hospital stays on surgical/urological wards were 6.0/2.9 days for open and laparoscopic procedures, respectively. CONCLUSION: In Denmark, the share of adrenalectomies performed laparoscopically is growing, currently reaching about 65%. Laparoscopic adrenalectomies are only performed at departments with a high frequency of laparoscopic surgery and specialized endocrinological and anaesthesiological support. For educational and research purposes, adrenalectomy should be performed at an even smaller number of departments. Postoperative hospital stay and mortality are at par with internationally reported levels, but the conversion rate of laparoscopic adrenalectomies should be reduced.

Transitional cell bladder tumor: predicting recurrence and progression by analysis of microsatellite loss of heterozygosity in urine sediment and tumor tissue.

Transitional cell bladder tumors (TCT) is prone to recurrence (60-80%) after tumor resection. Up to 25% of these patients will progress, so it is important to find reliable predictive markers. We analyzed for loss of heterozygosity (LOH) with respect to 13 microsatellites located on 10 different chromosomal arms. This analysis was performed on the urine sediment and tumor tissue from 59 patients with bladder TCT and on the urine and normal-looking mucosa from 25 patients with a history of bladder TCT but no evidence of disease at the time of the study inclusion. The median follow-up period was 23.1 months (range, 2-48 months) for the 59 patients with bladder TCT and 25 months (range, 4-57 months) for the 25 patients without evidence of ongoing active disease. Correlation between LOH and eventual recurrence, progression, and mortality was investigated. In patients with noninvasive TCT, correlation between 11p tumor tissue LOH and recurrence was found. Similarly, 8p LOH in both urine sediment and tumor tissue correlated with progression. Finally, in the group of patients with a history of bladder TCT, normal tissue 8p and/or 11p LOH correlated with recurrence.

Under-representation of bladder transitional cell tumour 9q, 11p and 14q LOH in urine and impact on molecular diagnosis.

BACKGROUND: To investigate whether the recently reported evidence of differences in the overall loss of heterozygosity (LOH) frequency between urine and tumour tissue in patients with transitional cell tumours (TCT) of the urinary bladder involved specific chromosomal sites, and their impact in diagnosis. MATERIALS AND METHODS: Blood, tissue and urine specimens were obtained from 55 patients and 25 controls. Sixteen microsatellites were PCR-amplified and blindly analyzed for LOH through a laser-based capillary electrophoresis system. RESULTS: Significant frequence differences between tumour tissue and urine sediment LOH were found in 9q and 11p in non-invasive disease and 14q in invasive disease. There was no significant difference for all the other chromosomal arms analyzed. CONCLUSION: The contribution in the urine sediment of cells belonging to tumours of the same histological classification differs according to the specific genetic alterations these cells carry. Furthermore, the location regarding these differences could indicate regions involved in tumour exfoliation or apoptosis.

Synthesis and biological evaluation of conformationally restricted and nucleobase-modified analogs of the anticancer compound 3'-C-ethynylcytidine (ECyd).

A series of conformationally restricted and nucleobase-modified analogs of the anticancer compound 3'-C-ethynylcytidine (ECyd) and its uracil analog (EUrd) have been synthesized. While none of the conformationally restricted analogs displayed anticancer activity, 5-iodo-EUrd and 5-bromo-EUrd displayed potent anticancer activity with IC50 values of 35 nM and 0. 73 microM.

Synthesis and biological evaluation of branched and conformationally restricted analogs of the anticancer compounds 3'-C-ethynyluridine (EUrd) and 3'-C-ethynylcytidine (ECyd).

The synthesis of branched and conformationally restricted analogs of the anticancer nucleosides 3'-C-ethynyluridine (EUrd) and 3'-C-ethynylcytidine (ECyd) is presented. Molecular modeling and (1)H NMR coupling constant analysis revealed that the furanose rings of all analogs except the LNA analog are conformationally biased towards South conformation, and are thus mimicking the structure of ECyd. All target nucleosides were devoid of anti-HIV or anticancer activity.

Synthesis and biological evaluation of nucleobase-modified analogs of the anticancer compounds 3'-C-ethynyluridine (EUrd) and 3'-C-ethynylcytidine (ECyd).

A series of nucleobase-modified analogs of the anticancer compounds 3'-C-ethynyluridine (EUrd) and 3'-C-ethynylcytidine (ECyd) were designed to overcome the strict substrate specificity of the activating uridine-cytidine kinase. EUrd, ECyd and target nucleosides were obtained using a short convergent synthetic route utilizing diacetone-alpha-D-glucose as starting material. 5-Iodo-substituted EUrd was the most potent inhibitor among the novel nucleobase-modified analogs in in vitro assays against human adenocarcinoma breast and prostate cancer cells with IC50 values down to 35 nM.

LNA-antisense rivals siRNA for gene silencing.

Locked nucleic acid (LNA) is a class of nucleic acid analogs possessing unprecedented binding affinity toward complementary DNA and RNA while obeying the Watson-Crick base-pairing rules. For efficient gene silencing in vitro and in vivo, fully modified or chimeric LNA oligonucleotides have been applied. LNA oligonucleotides are commercially available, can be transfected using standard techniques, are non-toxic, lead to increased target accessibility, can be designed to activate RNase H, and function in steric block approaches. LNA-Antisense, including gapmer LNA containing a central DNA or phosphorothioate-DNA segment flanked by LNA gaps, rivals siRNA as the technology of choice for target validation and therapeutic applications.

Locked nucleic acid: a potent nucleic acid analog in therapeutics and biotechnology.

Locked nucleic acid (LNA) is a class of nucleic acid analogs possessing very high affinity and excellent specificity toward complementary DNA and RNA, and LNA oligonucleotides have been applied as antisense molecules both in vitro and in vivo. In this review, we briefly describe the basic physiochemical properties of LNA and some of the difficulties that may be encountered when applying LNA technology. The central part of the review focuses on the use of LNA molecules in regulation of gene expression, including delivery to cells, stability, unspecific effects, toxicity, pharmacokinetics, and design of LNA oligonucleotides. The last part evaluates LNA as a diagnostic tool in genotyping.

Downregulation of p21(WAF1/CIP1) and estrogen receptor alpha in MCF-7 cells by antisense oligonucleotides containing locked nucleic acid (LNA).

Locked nucleic acid (LNA) is a nucleic acid analog with very high affinity to complementary RNA and a promising compound in the field of antisense research. The intracellular localization and quantitative uptake of oligonucleotides containing LNA were found to be equivalent to those of phosphorothioate oligonucleotides (PS AONs). The antisense efficiency of LNA-containing oligonucleotides was systematically compared with standard PS AONs targeting expression of two endogenous proteins in the human breast cancer cell line MCF-7, namely, the cyclin-dependent kinase inhibitor p21(WAF1/CIP1) and the estrogen receptor alpha (ERalpha). For downregulation of both target proteins, the most efficient design was achieved with oligonucleotides containing LNA monomers in the extremities and a central gap of PS-linked DNA monomers, so called LNA gapmers. Such LNA gapmers caused more potent downregulation of the targeted proteins than PS AONs, whereas fully modified LNA AONs or LNA mixmers (LNA nucleotides interspersed) were inactive.

New evaluation of plasma DNA microsatellite analysis in patients with TCC of the urinary bladder.

BACKGROUND: To determine the diagnostic value of plasma DNA microsatellite analysis in patients with transitional cell carcinoma (TCC) of the urinary bladder, by redefining plasma LOH from the equivalent analysis in controls. The method was further tested for MSI (microsatellite instability) and compared with tissue DNA analysis. MATERIALS AND METHODS: Sixteen microsatellites were amplified in leukocyte, plasma and tissue DNA from 40 patients and 28 controls, and analysed in a laser-based, capillary electrophoresis system. Plasma LOH was determined from the controls' cut-off values. RESULTS: The difference between plasma LOH frequency in patients (25% (10/40)) and controls (14% (4/28)) was not significant. Nevertheless, it occurred significantly more often in low rather than high-grade tumors (p=0.03) and controls (p=0.04). Plasma MSI was dependent upon the number of PCR cycles. Tissue LOH was present in 78% (31/40) of the patients and in none of the controls. Tissue MSI was uncommon. CONCLUSION: The results of plasma DNA microsatellite analysis in TCC need cautious interpretation.

Microsatellite analysis of urine sediment versus urine cytology for diagnosing transitional cell tumors of the urinary bladder.

The aim was to evaluate microsatellite analysis of urine sediment (MAUS) as an alternative method to urine cytology for routine diagnosis of patients with transitional cell tumors (TCT) of the urinary bladder. Urine cytology has the advantage of being non-invasive, fast and cheap, but is of limited value because of its low sensitivity. MAUS has previously been found to be a successful alternative method. However, the experimental set-up of such investigations implied exclusion of samples with unfavorable characteristics and use of a large number of markers. In the present study, MAUS was tested on all samples routinely available and a small panel of markers was selected. The urine sediments of 66 TCT patients and 24 controls were analyzed by MAUS with 16 fluorescent markers and by urine cytology. All samples were analyzed, including the ones of later micturition, with gross hematuria, leukocyturia or absence of visible sediment. In patients with tumors of low grade (grades I-II), MAUS was significantly more sensitive than urine cytology. The two methods were of equivalent diagnostic power in high-grade (grades III-IV), high-stage (pT1-pT4) tumors. A panel of the six most informative markers for MAUS was selected. Although MAUS has an advantage over routine cytology in low-grade, low-stage tumors, an overall sensitivity of 45% is not sufficient for routine clinical use.

Modulation of CpG oligodeoxynucleotide-mediated immune stimulation by locked nucleic acid (LNA).

Locked nucleic acid (LNA) is an RNA derivative that when introduced into oligodeoxynucleotides (ODN), mediates high efficacy and stability. CpG ODNs are potent immune stimulators and are recognized by toll-like receptor-9 (TLR9). Some phosphorothioate antisense ODNs bearing CpG dinucleotides have been shown to possess immune modulatory capacities. We investigated the effects of LNA substitutions on immune stimulation mediated by antisense ODN G3139 or CpG ODN 2006. LNA ODNs were tested for their ability to stimulate cytokine secretion from human immune cells or TLR9-dependent signaling. Phosphorothioate chimeric LNA/DNA antisense ODNs with phosphodiester-linked LNA nucleobases at both ends showed a marked decrease of immune modulation with an increasing number of 3' and 5' LNA bases. In addition, guanosine-LNA and cytosine-LNA or simply cytosine-LNA substitutions in the CpG dinucleotides of ODN 2006 led to strong decrease or near complete loss of immune modulation. TLR9-mediated signaling was similarly affected. These data indicate that increasing amounts of LNA residues in the flanks or substitutions of CpG nucleobases with LNA reduce or eliminate the immune stimulatory effects of CpG-containing phosphorothioate ODN.