Open retropubic prostatectomy in a patient with bladder exstrophy for management of hematuria and urethral discharge - A case report

Bladder exstrophy (BE) is a rare congenital disorder causing bladder and urethral malformation due to an abdominal wall embryological defect. Traditionally, BE had a poor life expectancy, but advances now offer a normal lifespan. A 57-year-old male with BE history and ureterosigmoidostomy repair presented with intractable hematuria, urethral discharge, and recurrent prostatic infections. He underwent retropubic subtotal prostatectomy without major complications, resolving urinary symptoms. Advances in BE management extend patient lifespans. This case demonstrates successful surgical management of hematuria and urethral discharge through radical prostatectomy in an adult with a history of BE.

Magnetic functionalization of ZnO nanoparticles surfaces via optically generated methyl radicals

The combination of nuclear and electron magnetic resonance techniques, in pulse and continuous wave regimes, is used to unravel the nature and features of the light-induced magnetic state arising at the surface of chemically prepared zinc oxide nanoparticles (NPs) occurring under 120 K when subjected to a sub-bandgap (405 nm) laser excitation. It is shown that the four-line structure observed around g ∼ 2.00 in the as-grown samples (beside the usual core-defect signal at g ∼ 1.96) arises from surface-located methyl radicals (•CH3), originating from the acetate capped ZnO molecules. By functionalizing the as-grown zinc oxide NPs with deuterated sodium acetate, the •CH3 electron paramagnetic resonance (EPR) signal is replaced by trideuteromethyl (•CD3). For •CH3, •CD3, and core-defect signals, an electron spin echo is detected below ∼100 K, allowing for the spin-lattice and spin-spin relaxation-time measurements for each of them. Advanced pulse-EPR techniques reveal the proton or deuteron spin-echo modulation for both radicals and give access to small unresolved superhyperfine couplings between adjacent •CH3. In addition, electron double resonance techniques show that some correlations exist between the different EPR transitions of •CH3. These correlations are discussed as possibly arising from cross-relaxation phenomena between different rotational states of radicals.

Regional anesthesia for ambulatory pediatric penoscrotal procedures

BACKGROUND/PURPOSE

Pediatric urology procedures are amongst the most commonly performed in children. The need for proactive treatment of pain is essential for optimal patient care. Current guidelines recommend the routine use of regional anesthesia in children as appropriate unless contraindicated. Given the commonality of urologic procedures in children, it is essential to understand the indications for and the utility of regional anesthesia.

METHODS

The current literature was searched using PubMed as the primary platform. Search words included 'dorsal penile nerve block,' 'pudendal nerve block,' 'ring block,' 'spinal anesthesia,' and 'caudal,' along with 'pediatric', 'circumcision,' 'hypospadias,' 'urology', and 'urological surgery' as part of the keywords of the search.

RESULTS

The articles resulting from the literature search were reviewed for content, clarity and study design by two co-authors, and agreement determined the incorporation into the review. Additionally, a detailed description of study design, regional anesthetic technique, local anesthetic(s) used, and outcomes of each study referenced was incorporated into the supplemental table.

CONCLUSION

Given the variance in block technique and local anesthetic choice amongst the current reported studies in the literature, it is difficult to truly compare and infer superiority of the regional anesthetic choices for ambulatory penoscrotal procedures. When choosing a regional anesthetic technique, careful consideration must be placed on block coverage, severity of expected pain and surgical duration of the procedure, type and dose of local anesthetic, as well as the patient's past medical history and anatomy. Moreover, the regional block chosen should result from a thorough preoperative discussion between the surgeon and the anesthesiologist.

Artificial intelligence: an attempt to automate remote device follow-up

Funding Acknowledgements

Type of funding sources: None.

Introduction

Artificial intelligence (AI) through machine learning (ML) refers to the simulation of human intelligence with the capacity for achieving goals within computers. In electrophysiology, ML has many applications in electrocardiography, intracardiac mapping and cardiac implantable electronic devices (CIEDs).

Remote monitoring (RM) of patients equipped with CIEDs associates the analysis of event reports and calendar-based remote follow-ups (FU). ML applications have allowed for risk stratification, improved arrhythmia localisation and streamlined remote monitoring which may significantly reduce the workload faced by electrophysiologists.

Aim

To develop a system that automates cardiac implantable electronic devices remote follow-up.

Methods and Results

We created a Java software application, that uses the latest optical character recognition techniques combined with artificial intelligence and natural language processing to extract information from PDF reports of RM of CIEDs from different manufacturers. The current version is HIPAA (Health Insurance Portability and Accountability Act) complaint and runs on local computers only.

Using the current system, we were able to run and extract data from 30 remote follow-up PDF reports of Cardiac Implantable Defibrillators (ICDs) and Cardiac Resynchronization Therapy with Defibrillator (CRT-Ds).

Time taken from data extraction to conversion of all 30 device PDFs was under 5 minutes.

Process and data extracted are presented in the figure below. (Figure 1)

Conclusion

This machine learning algorithm proved that it is possible to facilitate and automate remote follow-up of cardiac implantable electronic devices.

In a near future this will allow to us to efficiently increase productivity, by speeding and facilitating interpretation of remote device follow-ups, leading to improvements in patientcare and precision cardiovascular medicine.

Furthermore, in the current and future pandemics it may help prevent unnecessary in-person medical visits, avoiding additional, unnecessary strain on an already overburdened and overwhelmed healthcare system, and saving costs. Abstract Figure 1

The Resilient Child: Sex-Steroid Hormones and COVID-19 Incidence in Pediatric Patients

Coronavirus disease–2019 (COVID-19), a disease caused by Severe Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, has become an unprecedented global health emergency, with fatal outcomes among adults of all ages in the United States, and the highest incidence and mortality in adult men. As the pandemic evolves there is limited understanding of a potential association between symptomatic viral infection and age. To date, there is no knowledge of the role children (prepubescent, ages 9-13 years) play as “silent” vectors of the virus, with themselves being asymptomatic. Throughout different time frames and geographic locations, the current evidence on COVID-19 suggests that children are becoming infected at a significantly lower rate than other age groups—as low as 1%. Androgens upregulate the protease TMPRSS2 (type II transmembrane serine protease-2), which facilitates efficient virus-host cell fusion with the epithelium of the lungs, thus increasing susceptibility to SARS-CoV-2 infection and development of severe COVID-19. Owing to low levels of steroid hormones, prepubertal children may have low expression of TMPRSS2, thereby limiting the viral entry into host cells. As the world anticipates a vaccine against SARS-CoV-2, the role of prepubescent children as vectors transmitting the virus must be interrogated to prepare for a potential resurgence of COVID-19. This review discusses the current evidence on the low incidence of COVID-19 in children and the effect of sex-steroid hormones on SARS-CoV-2 viral infection and clinical outcomes of pediatric patients. On reopening society at large, schools will need to implement heightened health protocols with the knowledge that children as the “silent” viral transmitters can significantly affect the adult populations.

Spanish validation of Charlson index applied to prostate cancer

PURPOSE

Comorbidity assessment is essential in the triage of care for men with prostate cancer (PC). The aim of this study was to validate the Spanish version of the revised Charlson index (RCI) in PC.

MATERIALS AND METHODS

731 PC patients diagnosed from 1993 to 2008 were referred to our Radiation Oncology Department. The RCI classified patients into four categories RCI 0, RCI 1-2, RCI 3-4, and RCI 5 and higher. The Kaplan-Meier method and Cox proportional hazards modeling were used. We also analyzed the median age of patients who remained alive at the last control and those who died due to non-prostate cancer comorbidities.

RESULTS

636 patients were included median age: 70 years (44-85). The mean follow-up was 153.62 months, (6-288 months). Distribution of the D'Amico risk classification was 21%, 38.2%, and 40.8% for low, intermediate, and high risk, respectively. The RCI distribution categories were: 303 (46.7%) RCI 0, 102 (16%) RCI 1-2, 131 (20.6%) RCI 3-4, and 100 (15.7%) RCI 5 and higher. The probability of non-cause-specific mortality at 5 and 10 years was 2. 4% and 11.25% RCI 0, 3 and 14.1% RCI 1-2, 5.7% and 22.1% RCI 3-4, and 47% and 92% (RCI 5 and higher). The median age in the last control in patients alive or who had died by non-PC causes was 82.81 years (55.27-102).

DISCUSSION

The RCI may be used to aid medical decision making in older Spanish men with PC, especially in those with a high RCI 5 and higher.

Incorporation of Putative Helix-Breaking Amino Acids in the Design of Novel Stapled Peptides: Exploring Biophysical and Cellular Permeability Properties

Stapled α-helical peptides represent an emerging superclass of macrocyclic molecules with drug-like properties, including high-affinity target binding, protease resistance, and membrane permeability. As a model system for probing the chemical space available for optimizing these properties, we focused on dual Mdm2/MdmX antagonist stapled peptides related to the p53 N-terminus. Specifically, we first generated a library of ATSP-7041 (Chang et al., 2013) analogs iteratively modified by L-Ala and D-amino acids. Single L-Ala substitutions beyond the Mdm2/(X) binding interfacial residues (i.e., Phe3, Trp7, and Cba10) had minimal effects on target binding, α-helical content, and cellular activity. Similar binding affinities and cellular activities were noted at non-interfacial positions when the template residues were substituted with their d-amino acid counterparts, despite the fact that d-amino acid residues typically 'break' right-handed α-helices. d-amino acid substitutions at the interfacial residues Phe3 and Cba10 resulted in the expected decreases in binding affinity and cellular activity. Surprisingly, substitution at the remaining interfacial position with its d-amino acid equivalent (i.e., Trp7 to d-Trp7) was fully tolerated, both in terms of its binding affinity and cellular activity. An X-ray structure of the d-Trp7-modified peptide was determined and revealed that the indole side chain was able to interact optimally with its Mdm2 binding site by a slight global re-orientation of the stapled peptide. To further investigate the comparative effects of d-amino acid substitutions we used linear analogs of ATSP-7041, where we replaced the stapling amino acids by Aib (i.e., R84 to Aib4 and S511 to Aib11) to retain the helix-inducing properties of α-methylation. The resultant analog sequence Ac-Leu-Thr-Phe-Aib-Glu-Tyr-Trp-Gln-Leu-Cba-Aib-Ser-Ala-Ala-NH2 exhibited high-affinity target binding (Mdm2 Kd = 43 nM) and significant α-helicity in circular dichroism studies. Relative to this linear ATSP-7041 analog, several d-amino acid substitutions at Mdm2(X) non-binding residues (e.g., d-Glu5, d-Gln8, and d-Leu9) demonstrated decreased binding and α-helicity. Importantly, circular dichroism (CD) spectroscopy showed that although helicity was indeed disrupted by d-amino acids in linear versions of our template sequence, stapled molecules tolerated these residues well. Further studies on stapled peptides incorporating N-methylated amino acids, l-Pro, or Gly substitutions showed that despite some positional dependence, these helix-breaking residues were also generally tolerated in terms of secondary structure, binding affinity, and cellular activity. Overall, macrocyclization by hydrocarbon stapling appears to overcome the destabilization of α-helicity by helix breaking residues and, in the specific case of d-Trp7-modification, a highly potent ATSP-7041 analog (Mdm2 Kd = 30 nM; cellular EC50 = 600 nM) was identified. Our findings provide incentive for future studies to expand the chemical diversity of macrocyclic α-helical peptides (e.g., d-amino acid modifications) to explore their biophysical properties and cellular permeability. Indeed, using the library of 50 peptides generated in this study, a good correlation between cellular permeability and lipophilicity was observed.

Comparison of two identification and susceptibility test kits for Ureaplasma spp and Mycoplasma hominis in amniotic fluid of patients at high risk for intra-amniotic infection

Objective: Ureaplasma urealyticum and Mycoplasma hominis are the most common microorganisms found in the amniotic fluid of patients at risk for preterm delivery. However, culture techniques for genital mycoplasms require special conditions, are barely considered as part of the evaluation of suspected intra-amniotic infection (IAI) and the results are available within 2 and 7 days. The objectives of this study are to validate the use of two commercially available kits (Mycoplasma IES y MYCOFAST^® RevolutioN) for the identification of Ureaplasma spp. and Mycoplasma hominis in amniotic fluid, to compare the results of these kits with those obtained by culture and real-time polymerase chain reaction (qPCR) and to report the antibiotic sensitivity profile of the genital mycoplasms identified.Methods: This is a prospective cohort study including women with singleton and twin gestations between 16 and 36 weeks. Patients were admitted to perform an amniocentesis due to pregnancy complications considered at high risk for IAI (e.g. preterm labor with intact membranes, preterm prelabour rupture of membranes, short cervix, etc.), treatment of polyhydramnios, and for the assessment of fetal death and fever without a focus.Results: Overall, 93 patients underwent amniocentesis and 63 had results available for all tests. The prevalence of a positive culture was 6% (4/63). There were four cases of Ureaplasma spp. and none of Mycoplasma hominis. The qPCR identified one case as Ureaplasma spp., one case as Ureaplasma parvum and two cases as Ureaplasma urealyticum. For all tests, the diagnostic performance was as follows: sensitivity 100% [95% CI (39.8-100%)], specificity 100% [95% CI (93.9-100%)], positive predictive value 100% [95% CI (39.8-100%)] and negative predictive value 100% [95% CI (93.9-100%)]. In this cohort, Ureaplasma spp. showed low resistance to erythromycin, but a high resistance to clindamycin and clarithromycin that may change according to the antibiotic concentration.Conclusions: To our knowledge, this is the first study that validates the use of the Mycoplasma IES and MYCOFAST^® RevolutioN kits for the identification of genital mycoplasmas in amniotic fluid. The results of these kits are mostly available within 24 hours, have an excellent correlation with those from broth cultures and qPCR and characterize the antibiotic sensitivity profile of the genital mycoplasms identified, providing an opportunity for specific treatment in cases of IAI. Further validation studies in other populations are needed.

Postoperative adjuvant and very early salvage radiotherapy after prostatectomy in high-risk prostate cancer patients can improve specific and overall survival

PURPOSE

Adjuvant radiotherapy (ART) for biochemical relapse (BR) after radical prostatectomy (RP) showed increased disease-free survival (DFS) in three previous randomized trials. Retrospective phase II trials evaluated if early salvage RT (ESRT) is equivalent to ART. Our study aims to compare ART and ESRT to salvage RT.

MATERIALS AND METHODS

We compared RP plus ART and ESRT versus SRT. Indication for RT was made by PSA determination after RP: ART when PSA ≤ 0.2 ng/ml, ESRT when PSA ≤ 0.3 after PSA rise from 0.0 to SRT PSA ≥ 0.3. The cause of death of each patients was analyzed, DFS, cause-specific survival (CSS) overall survival (OS) and metastasis-free survival (MFS) in relation to RT intention.

RESULTS

Between 1993 and 2008, 204 patients with a median age of 65 years (44-75) were treated. The median follow-up was 160 months (28.1-273.3). At diagnosis, 89.7% had localized clinical stages and 90.2% had Gleason (G) ≤ 7. The median PSA was 10 (range 4-101). The postoperative G was ≥ 7 in 66.2%; 56.4% had ≥ 2 positive margins; 29.4% received ART, 20% ESRT and 59.3% SRT. The DFS for ART, ESRT and SRT was 74, 56 and 39% with significant differences between the three groups (p < 0.001). ART + ESRT were combined versus SRT; for the DFS, the significant differences (p < 0.001) remained 67% versus 39%. Positive margins, pT3 and pre-RT PSA were significant factors on multivariate analysis. The CSS in the ART + ESRT group was 92 vs. 78% in the SRT group (p < 0.05). OS was 69% in ART + ESRT vs. 57% in SRT (p < 0.05). MFS was 82.7% in ART + ESRT vs. 67.4% in SRT.

CONCLUSIONS

In this study the ART + ESRT presented benefits versus SRT in DFS, CSS, OS and MFS.

Macrocyclic α helical peptide therapeutic modality: A perspective of learnings and challenges

Macrocyclic α-helical peptides have emerged as a compelling new therapeutic modality to tackle targets confined to the intracellular compartment. Within the scope of hydrocarbon-stapling there has been significant progress to date, including the first stapled α-helical peptide to enter into clinical trials. The principal design concept of stapled α-helical peptides is to mimic a cognate (protein) ligand relative to binding its target via an α-helical interface. However, it was the proclivity of such stapled α-helical peptides to exhibit cell permeability and proteolytic stability that underscored their promise as unique macrocyclic peptide drugs for intracellular targets. This perspective highlights key learnings as well as challenges in basic research with respect to structure-based design, innovative chemistry, cell permeability and proteolytic stability that are essential to fulfill the promise of stapled α-helical peptide drug development.

Structure-activity studies of Mdm2/Mdm4-binding stapled peptides comprising non-natural amino acids

As primary p53 antagonists, Mdm2 and the closely related Mdm4 are relevant cancer therapeutic targets. We have previously described a series of cell-permeable stapled peptides that bind to Mdm2 with high affinity, resulting in activation of the p53 tumour suppressor. Within this series, highest affinity was obtained by modification of an obligate tryptophan residue to the non-natural L-6-chlorotryptophan. To understand the structural basis for improved affinity we have solved the crystal structure of this stapled peptide (M011) bound to Mdm2 (residues 6–125) at 1.66 Å resolution. Surprisingly, near identity to the structure of a related peptide (M06) without the 6-chloro modification is observed. Further analysis of linear and stapled peptides comprising 6-Me-tryptophan provides mechanistic insight into dual Mdm2/Mdm4 antagonism and confirms L98 of Mdm4 as a mutable steric gate. The results also highlight a possible role of the flexible hinge region in determining Mdm2/Mdm4 plasticity.

Epispadias repair with tunica vaginalis flap

INTRODUCTION

Primary epispadias is a rare congenital malformation that afflicts about 1 in 80,000 children. The surgical repair, originally described by Cantwell over 100 years ago, is fundamentally sound and incorporates several important steps to achieve an optimal result.

METHODS

A 9-month-old male with penopubic epispadias presented for surgical repair. Pre-operative imaging included a normal renal ultrasound and voiding cystourethrogram that demonstrated a moderate-sized bladder, partially competent bladder neck, and no vesicoureteral reflux. A modified Cantwell-Ransley approach to the repair was performed without complete disassembly of the penis. Established surgical principles of identification of laterally placed neurovascular bundles, preservation of the ventral mesentery to the urethral plate, mobilization of the urethral plate off the corporal bodies with ventral relocation, and dorsal medial rotation of the corporal bodies are demonstrated in this video.

RESULTS

This procedure was performed as an outpatient. The patient had an unremarkable postoperative course. The #6-French urethral stent was removed on postoperative day 10.

CONCLUSIONS

This video demonstrates a modified Cantwell-Ransley technique for epispadias repair, which employs a tunica vaginalis flap to reinforce the urethral repair. The adherence to surgical principles described by Cantwell in the late 1800s for children with primary epispadias continues to lead optimal surgical outcomes.

Transabdominal collection of amniotic fluid "sludge" and identification of Candida albicans intra-amniotic infection

A G3P2 patient who conceived while using an intrauterine contraceptive device (IUD) presented at 20 weeks of gestation with mild irregular uterine contractions and vaginal bleeding. Sonographic examination at admission showed the presence of dense amniotic fluid "sludge" and a long sonographic uterine cervix (42 mm). To assess the microbiologic significance of amniotic fluid "sludge", we performed a transabdominal amniocentesis. The procedure was performed under real-time ultrasound, and fluid resembling pus at gross examination was noted. Rapid amniotic fluid analysis showed the presence of a high white blood cell count and structures resembling hyphae. Amniotic fluid cultures were positive for Candida albicans. Treatment was begun with broad-spectrum antibiotics, including Fluconazole, upon the visualization of pus in the "sludge" material because of the presence of hyphae in the Gram stain. Despite treatment, the patient went into spontaneous preterm labor and delivered five days after admission. Placental examination revealed acute fungal histologic chorioamnionitis and funisitis. This represents the first report of transabdominal collection and analysis of amniotic fluid "sludge" and the microbiologic detection of Candida albicans in this material. This report provides evidence that transabdominal retrieval of "sludge" is possible and may be of significant value for patient management and selection of antimicrobial agents.

Bilateral Wilms Tumor With Ureteral Extension

Wilms tumor is the most common renal tumor in children. However, tumor extension into the ureter is exceedingly rare. We present a case of bilateral Wilms tumor with unilateral ureteral extension into the bladder. This case illustrates the importance of thoughtful diagnostic evaluation and surgical planning to obtain a good oncologic outcome while preserving renal function.

Surgical protocol violations in children with renal tumors provides an opportunity to improve pediatric cancer care: a report from the Children's Oncology Group

BACKGROUND

The purpose of this study was to evaluate the frequency and characteristics of surgical protocol violations (SPVs) among children undergoing surgery for renal tumors who were enrolled on the Children's Oncology Group (COG) renal tumor biology and classification study AREN03B2.

METHODS

AREN03B2 was opened in February 2006, and as on March 31, 2013, there were 3,664 eligible patients. The surgical review forms for 3,536 patients with unilateral disease were centrally reviewed for SPVs. The frequency, type, number of violations, institutional prevalence, and quartiles for SPVs were assessed.

RESULTS

Of the 3,536 patients, there were a total of 505 with at least one SPV (564 total SPVs reported), for an overall incidence of 14.28%. The types of SPVs included a lack of lymph node sampling in 365 (64.7%), avoidable spill in 61 (10.8%), biopsy immediately before nephrectomy in 89 (15.8%), an incorrect abdominal incision in 32 (5.7%), and unnecessary resection of organs in 17 (3.0%). The SPVs occurred in 163 of 215 participating institutions (75.8%). For centers with at least one SPV, the mean number of SPVs reported was 3.10 ± 2.39 (mean ± standard deviation). The incidence of protocol violation per institution ranged from 0 to 67%. Centers with an average of ≤1 case/year had an incidence of SPVs of 12.2 ± 3.8%, those with an average of >1 to <4 cases/year had an incidence of SPVs of 16.4 ± 3.6%, and those with an average of ≥4 cases/year had an incidence of SPVs of 12.6 ± 5.5% (P > 0.05).

CONCLUSIONS

SPVs that potentially result in additional exposure to chemotherapy and radiation therapy are not uncommon in children undergoing resection of renal malignancies.