Robot-Assisted Hysterectomy Using the Double-Bipolar Method

OBJECTIVE

To demonstrate the efficacy of the double-bipolar method in a benign hysterectomy.

DESIGN

Stepwise demonstration of the technique with a narrative video.

SETTING

The double-bipolar method was first reported in 2011 [1] and is gaining popularity in Japan; however, its usefulness in robot-assisted hysterectomy is under-reported. When unexpected bleeding occurs during robot-assisted hysterectomy using a monopolar technique, corrective measures may be prolonged and often require changing forceps. The Maryland forceps have 4 functions, including incision, dissection, grasping, and coagulation, which enable rapid responses to bleeding and reduce forceps changes and cost. Previously, we reported the usefulness of the double-bipolar technique in other surgical procedures [2,3]. Herein, we present a case of robot-assisted hysterectomy using this technique at an urban general hospital, including detailed insights into its execution.

INTERVENTIONS

A 45-year-old female patient presented to our hospital with painful menstrual bleeding. Magnetic resonance imaging revealed an 8-cm myoma in the posterior wall of the uterine cervix. Consequently, a robot-assisted hysterectomy was performed using right-handed Maryland forceps (Intuitive, Sunnyvale, CA) and the ForceTriadTM Energy Platform (Medtronic, Minneapolis, MN) in the macro mode, with an output of 60 W. This configuration ensured a consistent electronic output, regardless of the electrical resistivity of the target tissues, facilitating precise incisions using a momentary high voltage [4]. The surgical duration was 60 minutes, and the estimated blood loss was 5 mL.

CONCLUSION

The highly versatile double-bipolar method uses one forceps for incision, dissection, coagulation, and grasping and is useful in gynecological surgery. VIDEO ABSTRACT.

Effect of Uterine Weight on the Surgical Outcomes of Robot-Assisted Hysterectomy in Benign Indications

Background Uterine weight is an important factor in determining the complexity of a hysterectomy. Although greater uterine weight increases operative time and blood loss in open or laparoscopic surgery, it remains uncertain whether this applies to robot-assisted hysterectomy. This study aimed to investigate the effect of uterine weight on the surgical outcomes of robot-assisted hysterectomy. Methods We conducted a retrospective cohort study involving 872 patients who underwent robot-assisted hysterectomies at our institution between January 2019 and June 2022. Of these, 724 cases were analyzed and classified into four groups based on uterine weight: <250 g (377 patients), 250-500 g (253 patients), 500-750 g (69 patients), and ≥750 g (25 patients). We performed univariate analysis with the following endpoints: operation time, blood loss, postoperative hospital stay, complication rate, conversion to laparotomy rate, and blood transfusion rate. Results Operating time and blood loss increased significantly with greater uterine weight in the four groups (both p-values <0.01), but postoperative hospital stay and complication rate did not increase (p = 0.448, p = 0.679, respectively). None of the patients underwent conversion to laparotomy or blood transfusion. Conclusion Although the operating time for robot-assisted hysterectomy and blood loss increased with greater uterine weight, the complications and length of postoperative hospital stay were similar between groups. Robot-assisted hysterectomy is safe in cases of much uterine weight.

Robot-Assisted versus Laparoscopic Surgery for Pelvic Lymph Node Dissection in Patients with Gynecologic Malignancies

Objectives

The objective of this study was to compare the surgical outcomes for pelvic lymph node dissection (PLND) performed through conventional laparoscopic surgery (CLS) versus robot-assisted surgery (RAS) in patients with gynecologic malignancies.

Materials and Methods

Perioperative data, including operative time, estimated blood loss, and complications, were retrospectively analyzed in 731 patients with gynecologic malignancies who underwent transperitoneal PLND, including 460 and 271 in the CLS and RAS groups, respectively. Data were statistically analyzed using the Chi-square test or Student's t-test as appropriate. P < 0.05 was considered statistically significant.

Results

The mean age was 50 ± 14 years and 53 ± 13 years in the RAS and CLS groups (P < 0.01), respectively. The mean body mass index was 23.4 ± 4.8 kg/m2 and 22.4 ± 3.6 kg/m2 in the RAS group and CLS groups (P < 0.01), respectively. The operative time, blood loss, and number of resected lymph nodes were 52 ± 15 min, 110 ± 88 mL, and 45 ± 17, respectively, in the RAS group and 46 ± 15 min, 89 ± 78 mL, and 38 ± 16, respectively, in the CLS group (all P < 0.01). The rate of Clavien-Dindo Grade ≥ III complications was 6.3% and 8.7% in the RAS and CLS groups, respectively (P = 0.17).

Conclusion

Shorter operative time and lower blood loss are achieved when PLND for gynecologic malignancies is performed through CLS rather than RAS. However, RAS results in the resection of a greater number of pelvic lymph nodes.

Extraovarian Dysgerminoma Involving the Uterine Cervix: A Rare Case Report With Literature Review

Primary extraovarian dysgerminoma (EOD) is a very rare disease. There is no literature about primary EOD involving the uterine cervix. We herein present details of a unique case of primary EOD involving the uterine cervix. A 46-year-old woman with uterine cervical tumor was referred to our institution with atypical genital bleeding. A polypoid tumor localized to the uterine cervix was found. Cervical biopsy detected malignant components of likely nonepithelial cell origin. Preoperative imaging examinations showed a uterine cervical tumor measuring ~5 cm, suggestive of malignancy without distant or lymph node metastases. The patient underwent abdominal radical hysterectomy with pelvic lymph node dissection according to the standard treatment for stage IB3 cervical cancers. The pathological diagnosis was dysgerminoma involving the uterine cervix and the right fallopian tube. Immunohistochemical results were as follows: SALL4 (+), octamer-binding transcription factor 4 (+), D2-40 (+), and c-Kit (+). She received 3 cycles of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. The disease did not recur up to 14 months after surgery. This is the first-ever published case of primary EOD involving the uterine cervix among previously reported EOD cases. Reported cases of EOD in female genital tract are also reviewed. Our case provides more extensive insights for pathologists to consider the differential diagnosis of cervical lesions. In our case, combination therapy involving a surgical approach-according to cervical cancers and adjuvant chemotherapy as used for ovarian dysgerminomas-was effective. Future verification is needed regarding the best approach for treating uterine cervical dysgerminomas.

Comparison of the Efficacy of Low Dose Tadalafil with Tamsulosin against Lower Urinary Tract Symptoms and Sexual Dysfunction after Low Dose Rate Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Patients with clinically localized prostate cancer (PCa) can be curatively treated with different modalities, including low dose rate (LDR) prostate brachytherapy (PB). LDR-PB allows the patient a relatively short recovery time compared with other treatment modalities such as prostatectomy. However, PB might exert distinct impact on quality of life, lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) are two major concerns. The aim of present study was to assess prospectively the efficacy of low dose tadalafil treatment on both SD and LUTS compared with tamsulosin treatment in patients treated PB for localized PCa.

MATERIALS/METHODS

Patients scheduled for PB with I-125 seeds for low or intermediate-risk localized PCa at our institution were eligible for this study. The prescribed dose was set at 160 gray. Participants were randomized into two groups; those started treating with a daily use of 0.2 mg of tamsulosin hydrochloride or 5 mg of tadalafil just after PB. The duration of the study was 12 months and the patients were assessed for urinary and sexual function status at baseline, and 1, 3, 6, and 12 months after PB. The primary study endpoints were both changes from baseline in urinary and sexual function status.

RESULTS

Between July 2015 and August 2020, 120 participants were enrolled in this study. The median age was 68 years with the median PSA of 6.5 ng/ml. A total 15 patients were excluded within 6 months after randomization. All subjective LUTS findings, including International Prostate Symptom Score (IPSS), and Over Active Bladder Symptom Score (OABSS), were significantly deteriorated at 1, 3, and 6 months after PB compared with baseline in both groups, respectively (p<0.05). Among objective LUTS findings, a significant decrease in maximum urinary flow rate (Qmax) was found at 1, 3, 6, and 12 months after PB compared with baseline in both groups, respectively (p<0.05). A significant increase in post void residual urine (PVR) was found at 1, 3, and 6 months after PB compared to baseline in tadalafil group, whereas no significant increase was seen in tamsulosin group. There were no statistically significant differences between the 2 groups in scores of the total International Index of Erectile Function (IIEF)-15 and Erection Hardness Score (EHS) before and at 1 month post PB. The EHS was significantly higher in tadalafil group compared with tamsulosin group at 3, 6 and 12 months (p = 0.001, p = 0.004, and p = 0.019, respectively). The EHS after PB in tadalafil group was not significantly decreased from baseline.

CONCLUSION

After LDR-PB, tamsulosin treatment significantly decreased PVR compared with tadalafil. On the other hand, tadalafil contributed to maintain erection hardness compared with tamsulosin.

Nerve-sparing surgery for deep lateral parametrial endometriosis

OBJECTIVE

Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE).

DESIGN

Stepwise demonstration of this method with a narrated video footage.

SETTING

An urban general hospital.

PATIENT(S)

A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots.

INTERVENTION(S)

Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure.

MAIN OUTCOME MEASURE(S)

Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization).

RESULT(S)

The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved.

CONCLUSION(S)

Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.

Robot-assisted Exploration of Somatic Nerves in the Pelvis and Transection of the Sacrospinous Ligament for Alcock Canal Syndrome

STUDY OBJECTIVE

Some articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1], transgluteal [2], or conventional laparoscopic approach [3,4]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS.

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament.

INTERVENTIONS

The procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6]: step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months.

CONCLUSION

Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7].

The temporal evolution of income polarization in Canada's largest CMAs

Income polarization is a pressing issue which is increasingly discussed by academics and policymakers. The present research examines income polarization in Canada’s eight largest Census Metropolitan Areas (CMAs) using data at the census-tract (CT) level between 1971 and 2016. Generally, there are significant decreasing trends in the middle-income population with simultaneously increasing trends in low-income groups. The high-income groups have been relatively stable with fewer significant increasing population trends. Using conventional mapping and cartograms, patterns of the spatial evolution of income inequality are illustrated. Every CMA examined contains an increasing trend of spatial fragmentation at the patch level within each CMA’s landscape mosaic. The results of a spatial autocorrelation analysis at the sub-patch, CT level, exhibit significant spatial clustering of high-income CTs as one process that dominates the increasingly fragmented landscape mosaic.

Robot-assisted total extraperitoneal para-aortic and pelvic lymphadenectomy

Robot-assisted extraperitoneal para-aortic lymphadenectomy has been reported to be feasible option for the surgical management of gynecologic malignancy previously (Narducci et al., 2009) (Hudry et al., 2019). We have reported the feasibility of laparoscopic extraperitoneal total para-aortic and pelvic lymphadenectomy (Andou, 2016). This article aims to show the safety of robot-assisted extraperitoneal "total para-aortic and pelvic" lymphadenectomy. The video is the staging surgery for 67-year-old woman suspected clinical stage IA ovarian clear cell carcinoma after abdominal hysterectomy and salpingo-oophorectomy. As abdominal adhesion was predicted, she was treated using robot-assisted extraperitoneal total para-aortic and pelvic lymphadenectomy. The patient was placed in the supine position and tilted 7 degrees to the right. Three robot arms were docked at the patient's left side. The center port was used for the scope. The bipolar cutting method was performed using the surgeon's right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the extraperitoneal space was expanded, lymphadenectomy was performed up to the renal veins and below to the obturator muscles using the bipolar cutting method. This was followed by omentectomy. The operative time were 189 min, and the estimated blood loss was 75 ml. A total of 56 lymph nodes were harvested (22 para-aortic lymph nodes and 34 pelvic lymph nodes). Total extraperitoneal lymphadenectomy by robot-assisted surgery was a feasible procedure for this patient. The procedure, which does not require the Trendelenburg position and is not obstructed by bowel, may be suitable for patients with hypertension, glaucoma, obesity or abdominal adhesion.

Clinical use of indocyanine green during nerve-sparing surgery for deep endometriosis

OBJECTIVE

To describe the anatomic and technical highlights of a novel nerve-sparing surgery in deep endometriosis (DE) using near-infrared (NIR) fluorescence technology and indocyanine green (ICG).

DESIGN

Stepwise demonstration of this method with narrated video footage.

SETTING

An urban general hospital.

PATIENT(S)

A 48-year-old woman was referred for severe chronic pelvic pain, dysmenorrhea, and pain on defecation, all of which were resistant to medication therapy. Magnetic resonance imaging revealed uterine adenomyosis and left ovarian endometrioma with DE involving the uterosacral ligament, posterior cervix, and surface of the rectum, with complete cul-de-sac obliteration.

INTERVENTION(S)

An intravenous injection of 0.25 mg/kg body weight of ICG for intraoperative NIR fluorescence imaging. Ethics approval was obtained from the institutional review board at our hospital (IRB No.: 985).

MAIN OUTCOME MEASURE(S)

Evaluation of blood perfusion of DE nodule and achieving better visualization of anatomic relationship to the pelvic autonomic nerves.

RESULT(S)

The procedure was performed using the following eight steps with the da Vinci Xi surgical platform: Step 0, observing peritoneal endometriotic lesions; Step 1, adhesiolysis and adnexal surgery; Step 2, separation of the nerve plane; Step 3, dissection of the ureter; Step 4, reopening of the pouch of Douglas; Step 5, complete removal of DE lesions while avoiding injury to the nerve plane; Step 6, hysterectomy (if the patient desires nonfertility-sparing surgery); Step 7, checking for rectal injury using air leakage test and tissue perfusion; and Step 8, barrier agents for adhesion prevention. During surgery, we could easily identify ischemic nodules, which included DE and fibrosis under NIR fluorescence imaging, beyond the limits of macroscopic disease. Endometriosis or fibrosis was confirmed pathologically from all resected tissues, and resection margins of these tissues were negative for the disease. These results suggest that this technique might be feasible for objectively identifying the border between DE lesions and healthy tissue. Furthermore, the hypogastric nerve and inferior hypogastric plexus were strongly highlighted by ICG and objectively preserved with the assessment of perfusion. The patient developed no perioperative complications, including postoperative bladder or rectal dysfunction after surgery.

CONCLUSION(S)

To our knowledge, this is the first reported use of ICG during nerve-sparing surgery for gynecologic disease. Application of ICG with NIR fluorescence appears potentially useful, not only to remove DE, but also to improve nerve-sparing.

Association between socioeconomic indicators and geographic distribution of vestibular schwannomas in West Scotland: a 15-year review

OBJECTIVE

Socioeconomic risk factors may contribute to geographic variation in diseases, but studies are limited due to lack of large available cohorts.

METHOD

A geographic analysis was performed of the association between socioeconomic risk factors and the distribution of vestibular schwannomas in adults diagnosed with sporadic vestibular schwannomas through the National Health Services in the West of Scotland from 2000 to 2015.

RESULTS

A total of 511 sporadic vestibular schwannomas were identified in a population of over 3.1 million. Prevalence of vestibular schwannomas were lowest in cases with good health (-0.64, 95 per cent confidence interval: -0.93,-0.38; p = 0.002) and level 1 qualifications (-0.562, 95 per cent confidence interval: -0.882 to -0.26; p = 0.01). However, these risk factors did not demonstrate consistent linearity of correlations. Prevalence was lower in people originating from European Union accession countries from April 2001 to March 2011 (-0.63, 95 per cent confidence interval: -0.84 to -0.43; p = 0.002). No correlation between distribution of vestibular schwannomas and socioeconomic risk factors met our threshold criteria (± 0.7).

CONCLUSION

This study demonstrated that there is little variation in distribution of vestibular schwannomas by socioeconomic risk factors.

Robotic Radical Trachelectomy Using the Double Bipolar Method- Aiming for a Bloodless Operative Field

Study Objective

To report the application of the double bipolar technique in a patient with 1b1 cervical cancer who wished to preserve her fertility potential.

Design

After experiencing 105 cases of laparoscopic and robotic radical trachelectomy with a 5 year survival rate of 98% and the birth of 29 babies from 51 of these patients who attempted pregnancy, we introduced the double bipolar method to overcome technical difficulties of the procedure due to the necessity for precise dissection and reconstruction in the deep pelvis. We will show our operative techniques, such as nerve sparing radical trachelectomy and retroperitoneal lymphadenectomy for early invasive cervical cancer in a bloodless operative field.

Setting

Urban general hospital.

Patients or Participants

Robotic radical trachelectomy using the double bipolar method was performed in three patients with 1b1 cervical cancer.

Interventions

After Robotic radical trachelectomy using monopolar scissors in 30 cases of stage Ib1 cervical cancer, we considered techniques for a more bloodless operative field. The double bipolar method (DBM) was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. Using robotic Maryland forceps as a cutting device allows for pinpoint accuracy that cannot be found in other instruments. It is important for bladder and ureteral dissection and exposure of vessels. Cuts are made at a very limited point by a lightning strike mechanism, meaning there is minimal thermal spread to adjacent organs.

Measurements and Main Results

Blood loss was 250ml in the cases presented. In surgeries not using the DBM(n=34), the blood loss ranged from 350ml(100-1200ml). While there is no supporting data, the dissection of the ureter was very smooth.

Conclusion

A bloodless operative field allows for accurate dissection and can prevent intraoperative injuries. The double bipolar method is able to provide precision cutting and limit thermal spread to adjacent tissue, reducing injury and allowing for a clear operative field.

Robot-assisted Nerve Plane-sparing Eradication of Deep Endometriosis with Double-bipolar Method

OBJECTIVE

To demonstrate anatomic and technical highlights of a robot-assisted nerve plane-sparing eradication of deep endometriosis (DE).

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

An urban general hospital.

INTERVENTIONS

Laparoscopic nerve-sparing techniques as represented by the Negrar method reportedly result in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches [1]. In addition, robotic surgery has become available, and 2 meta-analyses have confirmed that robotic surgery is safe and feasible for the treatment of endometriosis, especially in advanced cases [2,3]. However, few papers have shown the surgical techniques for a nerve-sparing procedure using a robotic approach. The patient was a 45-year-old woman who presented with severe chronic pelvic pain and dysmenorrhea resistant to medication therapy. She had no nerve-specific complaints such as pain in the pudendal distribution or a voiding dysfunction. Magnetic resonance imaging revealed multiple uterine fibromas and adenomyosis with DE, involving the uterosacral ligament and surface of the rectum, with cul-de-sac obliteration. The parametrium was not involved in the DE. Robot-assisted nerve plane-sparing excision of DE with a double-bipolar method was performed using the following 8 steps: step 1, adhesiolysis and adnexal surgery; step 2, checking the ureteral course; step 3, separation of the nerve plane (step 3.1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia; and step 3.2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and fascia propria of the rectum) [4,5]; step 4, reopening of the pouch of Douglas; step 5, complete removal of DE lesions while avoiding injury to the nerve plane; step 6, hysterectomy (if the patient desires non-fertility-sparing surgery); step 7, checking for rectal injury using an air leakage test; and step 8, barrier agents for adhesion prevention. With regard to step 3, as a result of sharp dissection between avascular layers both above and below the hypogastric nerve, autonomic nerves in the pelvis were separated like a sheet with the surrounding fascia (the nerve plane). We then performed steps 4 to 6 in a step-by-step manner while avoiding injury to the nerve plane. The urinary catheter was removed within 24 hours after the surgery, and no residual urine was seen. The patient developed no perioperative complications; in particular, no postoperative bladder or rectal dysfunctions. The precise sharp dissection of the right embryo-anatomic planes on the basis of the detailed mesoanatomy seems important for improving functional outcomes in nerve-sparing surgery [5].

CONCLUSION

Robot-assisted nerve plane-sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help surgeons perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete. However, the latent benefits of robot-assisted nerve-sparing surgery in the treatment of DE remain uncertain.

Roles of Re-entrant cluster glass state and spin-lattice coupling in magneto-dielectric behavior of giant dielectric double perovskite La1.8Pr0.2CoFeO6

La based Co-Fe combined double perovskite (La1.8Pr0.2CoFeO6) was synthesized and the dielectric (zero-field and in-field), magnetic, x-ray absorption and Raman spectroscopy measurements have been investigated for La1.8Pr0.2CoFeO6 double perovskite. The existence of re-entrant cluster glass state is observed. The magneto-dielectric (MD) is found in two temperature regions (25-80 K and 125-275 K). It has been demonstrated that the observed MD at low and high temperatures are respectively due to the spin freezing and the spin-lattice coupling. Furthermore, the very large dielectric constant and the low loss suggest that La1.8Pr0.2CoFeO6 is very important from the application point of view.

AB0619 PROGNOSTIC FACTORS OF PATIENTS WITH ANTI-MDA5 ANTIBODY-POSITIVE DERMATOMYOSITIS COMPLICATED WITH INTERSTITIAL PNEUMONIA -A JAPANESE SINGLE CENTER STUDY-

Background:

Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is frequently associated with rapidly progressive interstitial pneumonia (RPIP), whose prognosis is assumed to be poor[1]. Although outcome of DM-RPIP has been reported to be improved by early immunosuppressive therapy, we still experience the cases with severe outcome. Only several reports mentioned the prognostic factors and they have not been fully elucidated.

Objectives:

To identify the predictors of prognosis in patients with anti-MDA5 Ab-positive DM associated with interstitial pneumonia (DM-IP).

Methods:

Anti-MDA5 Ab-positive DM-IP patients admitted to Fujita Health University Hospital between January 2010 and October 2019 were consecutively included and stratified into 2 groups, the survived and the deceased groups. DM was diagnosed according to the criteria proposed by Bohan and Peter[2]. Clinically amyopathic DM was diagnosed according to the criteria proposed by Sontheimer [3]. Diagnosis of IP was based on findings of high resolution CT scan (HRCT). The definition of RPIP was rapid exacerbation of hypoxemia or HRCT findings in a period of days to one month after the onset. Clinical features and prognosis of the patients were collected retrospectively and compared between groups. Candidates of predictors are extracted by the univariable analysis using Fisher’s exact test for dichotic parameters and Wilcoxon signed-rank test for continuous parameters and multivariable analysis using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was examined to obtain the cut-off level. Survival was examined using Kaplan-Meier method and Log-rank test.

Results:

Twenty-one patients were involved. Eight were deceased and 13 were survived. The deceased group had a higher ratio of male (75% versus 25%, p= 0.018). All deceased cases were with RPIP and 67 % in the survived cases. Levels of serum ferritin (4490 versus 646 ng/mL, p = 0.0026), CRP (2.1 versus 0.9 mg/dL, p = 0.0490), CK (1150 versus 290 U/L, p = 0.017), AST (194 versus 108 U/L, p = 0.025) and LDH (674 versus 368 U/L, p = 0.011) were higher in the deceased group. Interestingly, skin ulcers were tended to be more frequent (12.5% versus 87.5%, p= 0.0587), and anti-SS-A antibody was also more frequently detected (14.3% versus 85.7%, p=0.0072) in the survived group. Using ROC analysis cut-off values were 963 ng/mL for serum ferritin level (sensitivity 100%, specificity 83%), 0.7 mg/dL for CRP (sensitivity 75%, specificity 69%), 308 U/L for CK (sensitivity 88%, specificity 77%), 62 U/L for ALT (sensitivity 100%, specificity 62%), and 454 U/L for LDH (sensitivity 88%, specificity 77%). Patients were divided into two groups based on these cut-offs or based on dichotic parameters and survival was examined between 2 groups. Except CRP and anti-SS-A antibody, survival was significantly worse in parameter-positive or higher groups. Interestingly, anti-SS-A antibody-positive group had better outcome compared with those without.

Conclusion:

In our analysis, novel candidates such as serum CK, AST, and LDH levels were newly extracted and parameters previously reported was also included and those were also associated with the clinical outcome. In addition, anti-SS-A antibody was identified as a novel protective factor associated with a good outcome.

References:

[1]Nakashima R, Hosono Y, Mimori T. Clinical significance and new detection system of autoantibodies in myositis with interstitial lung disease. Lupus 2016;25:925-33.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Eng J Med 1975;292:344-7.

[3]Sontheimer RD. Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin 2000;20:387-408.

Disclosure of Interests:

None declared

Short-term outcomes of robot-assisted versus conventional laparoscopic surgery for early-stage endometrial cancer: A retrospective, single-center study

AIM

We compared the short-term outcomes between conventional laparoscopic surgery (CLS) and robot-assisted surgery (RAS) to assess the technical feasibility of the latter for early-stage endometrial cancer.

METHODS

We retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early-stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para-aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups.

RESULTS

No differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P < 0.01), mean blood loss was 196 ± 153 versus 237 ± 146 mL (P = 0.047), mean length of postoperative hospital stay was 9 ± 4 versus 8 ± 3 days (P = 0.01) and mean rate of perioperative complications of Clavien-Dindo grade III or higher was 2.0 versus 3.4% (P = 0.53) for the CLS versus RAS groups, respectively. There was no significant difference in the number of resected lymph nodes.

CONCLUSION

The operative time was significantly longer and blood loss was significantly greater in the RAS group than in the CLS group, without a significant difference in the number of resected lymph nodes. These differences are within an acceptable clinical range, showing that RAS is feasible and safe for early-stage endometrial cancer, providing short-term outcomes comparable to those of conventional surgery. Future studies are warranted to compare the long-term oncological outcomes by extending the observation period and including para-aortic lymphadenectomy data.

Long-term oncological outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer: A retrospective, single-institutional study in the wake of the LACC trial

AIM

The objective of this study was to investigate the long-term oncological outcomes of minimally invasive radical hysterectomy (MIRH) for the treatment of early-stage cervical cancer retrospectively in the wake of the laparoscopic approach to cervical cancer (LACC) trial.

METHODS

A total of 109 patients with stage IA1 with lymphovascular space involvement, IA2, and IB1 cervical cancers were included in this study. The surgical and oncological outcomes were retrospectively evaluated. All patients underwent type C MIRH with a no-touch isolation technique for cervical tumor.

RESULTS

The median number of resected pelvic lymph nodes was 36 (range, 14-94), and 10 patients (9.2%) had positive nodes. One patient (0.9%) had positive surgical margins. Forty-six patients (42%) underwent adjuvant therapy. The median follow-up time was 73 months (range, 30-146 months). Five patients (4.6%) developed recurrent disease, and 3 patients (2.8%) died of cervical cancer. The 5-year disease-free survival and overall survival rates were 96.3% and 97.2%, respectively. A comparison between patients with tumor diameter ≤ 2 cm (n = 59) and those with tumor diameter > 2 cm (n = 50) did not identify any significant differences, with 5-year disease-free survival 96.6% versus 94.0% and 5-year overall survival 98.3% versus 96.0%, respectively.

CONCLUSION

In this retrospective study, MIRH with a no-touch isolation technique for stage IA to IB1 cervical cancer was a safe approach in terms of oncological outcomes. However, every surgeon who treats early-stage cervical cancer should inform each patient of the results of the LACC trial because it has an exceedingly high impact.

Investigation of multi-mode spin-phonon coupling and local B-site disorder in Pr2CoFeO6 by Raman spectroscopy and correlation with its electronic structure by XPS and XAS studies

Electronic structure of Pr₂CoFeO₆ (at 300 K) was investigated by x-ray photoemission spectroscopy (XPS) and x-ray absorption spectroscopy techniques. All three cations, i.e. Pr, Co and Fe were found to be trivalent in nature. XPS valance band analysis suggested the system to be insulating in nature. The analysis suggested that Co³⁺ ions exist in low spin state in the system. Moreover, Raman spectroscopy study indicated the random distribution of the B-site ions (Co/Fe) triggered by same charge states. In temperature-dependent Raman study, the relative heights of the two observed phonon modes exhibited anomalous behaviour near magnetic transition temperature T _N ~ 270 K, thus indicating towards interplay between spin and phonon degrees of freedom in the system. Furthermore, clear anomalous softening was observed below T _N which confirmed the existence of strong spin-phonon coupling occurring for at least two phonon modes of the system. The line width analysis of the phonon modes essentially ruled out the role of magnetostriction effect in the observed phonon anomaly. The investigation of the lattice parameter variation across T _N (obtained from the temperature-dependent neutron diffraction measurements) further confirmed the existence of the spin-phonon coupling.

Deep mapping gentrification in a large Canadian city using deep learning and Google Street View

Gentrification is multidimensional and complex, but there is general agreement that visible changes to neighbourhoods are a clear manifestation of the process. Recent advances in computer vision and deep learning provide a unique opportunity to support automated mapping or ‘deep mapping’ of perceptual environmental attributes. We present a Siamese convolutional neural network (SCNN) that automatically detects gentrification-like visual changes in temporal sequences of Google Street View (GSV) images. Our SCNN achieves 95.6% test accuracy and is subsequently applied to GSV sequences at 86110 individual properties over a 9-year period in Ottawa, Canada. We use Kernel Density Estimation (KDE) to produce maps that illustrate where the spatial concentration of visual property improvements was highest within the study area at different times from 2007–2016. We find strong concordance between the mapped SCNN results and the spatial distribution of building permits in the City of Ottawa from 2011 to 2016. Our mapped results confirm those urban areas that are known to be undergoing gentrification as well as revealing areas undergoing gentrification that were previously unknown. Our approach differs from previous works because we examine the atomic unit of gentrification, namely, the individual property, for visual property improvements over time and we rely on KDE to describe regions of high spatial intensity that are indicative of gentrification processes.

A direct observation method for auditing large urban centers using stratified sampling, mobile GIS technology and virtual environments

BACKGROUND

With the expansion and growth of research on neighbourhood characteristics, there is an increased need for direct observational field audits. Herein, we introduce a novel direct observational audit method and systematic social observation instrument (SSOI) for efficiently assessing neighbourhood aesthetics over large urban areas.

METHODS

Our audit method uses spatial random sampling stratified by residential zoning and incorporates both mobile geographic information systems technology and virtual environments. The reliability of our method was tested in two ways: first, in 15 Ottawa neighbourhoods, we compared results at audited locations over two subsequent years, and second; we audited every residential block (167 blocks) in one neighbourhood and compared the distribution of SSOI aesthetics index scores with results from the randomly audited locations. Finally, we present interrater reliability and consistency results on all observed items.

RESULTS

The observed neighbourhood average aesthetics index score estimated from four or five stratified random audit locations is sufficient to characterize the average neighbourhood aesthetics. The SSOI was internally consistent and demonstrated good to excellent interrater reliability. At the neighbourhood level, aesthetics is positively related to SES and physical activity and negatively correlated with BMI.

CONCLUSION

The proposed approach to direct neighbourhood auditing performs sufficiently and has the advantage of financial and temporal efficiency when auditing a large city.