The role of neoadjuvant chemotherapy for patients with variant histology muscle invasive bladder cancer undergoing robotic cystectomy: Data from the International Robotic Cystectomy Consortium

OBJECTIVE

To assess the role of neoadjuvant chemotherapy (NAC) before robot-assisted radical cystectomy (RARC) for patients with variant histology (VH) muscle-invasive bladder cancer (MIBC).

METHODS

Retrospective review of 988 patients who underwent RARC (2004-2023) for MIBC. Primary outcomes included the utilization of NAC among this cohort of patients, frequency of downstaging, and discordance between preoperative and final pathology in terms of the presence of VH. Secondary outcomes included disease-specific (DSS), recurrence-free (RFS), and overall survival (OS).

RESULTS

A total of 349 (35%) had VH on transurethral resection or at RARC. The 4 most common VH subgroups were squamous (n = 94), adenocarcinoma (n = 64), micropapillary (n = 34), and sarcomatoid (n = 21). There was no difference in OS (log-rank: P = 0.43 for adenocarcinoma, P = 0.12 for micropapillary, P = 0.55 for sarcomatoid, P = 0.29 for squamous), RFS (log-rank: P = 0.25 for adenocarcinoma, P = 0.35 for micropapillary, P = 0.83 for sarcomatoid, P = 0.79 for squamous), or DSS (log-rank P = 0.91 for adenocarcinoma, P = 0.15 for micropapillary, 0.28 for sarcomatoid, P = 0.92 for squamous) among any of the VH based on receipt of NAC. Patients with squamous histology who received NAC were more likely to be downstaged on final pathology compared to those who did not (P < 0.01).

CONCLUSION

Our data showed no significant difference in OS, RFS, or DSS for patients with VH MIBC cancer who received NAC before RARC. Patients with the squamous variant who received NAC had more pathologic downstaging compared to those who did not. The role of NAC among patients with VH is yet to be defined. Results were limited by small number in each individual group and lack of exact proportion of VH.

Artificial Intelligence in Urology: Current Status and Future Perspectives

Surgical fields, especially urology, have shifted increasingly toward the use of artificial intelligence (AI). Advancements in AI have created massive improvements in diagnostics, outcome predictions, and robotic surgery. For robotic surgery to progress from assisting surgeons to eventually reaching autonomous procedures, there must be advancements in machine learning, natural language processing, and computer vision. Moreover, barriers such as data availability, interpretability of autonomous decision-making, Internet connection and security, and ethical concerns must be overcome.

In vitro antimicrobial and antioxidant activities, essential oil composition, and in silico molecular modeling analysis of secondary metabolites from roots of Verbascum sinaiticum

Verbascum sinaiticum is locally used to treat wound, stomachache, viral infection, cancer, sunstroke fever, abdominal colic, diarrhea, hemorrhage, anthrax, and hepatitis. The objective of this study was to identify the compounds and to evaluate the antimicrobial and antioxidant activity of the extracts and isolated compounds from V. sinaiticum. The 1H-NMR, 13C-NMR, and DEPT-135 were used to elucidate the structures of isolated compounds. Essential oils were extracted by hydrodistillation method and their chemical analyses were performed by GC-MS. The broth microdilution method was used to evaluate the antimicrobial activity. The radical scavenging activity of the extracts and isolated compounds were evaluated using DPPH method. Silica gel column chromatographic separation of root extracts afforded seven known compounds: 3'-(4''-methoxy phenyl)-3'-oxo-propionyl hexadecanoate (1), harpagoside (2), pulverulentoside I (3), scrophuloside B4 (4), scropolioside A (5), scropolioside-D2 (6), and harpagide 6-O-β-glucoside (7), which are all reported from this species for the first time. The EO extracts from leaves and roots were the most susceptible to Streptococcus agalactiae, with a 2 mg/mL MIC. The EO from roots was effective against Candida albicans and Trichophyton mentagrophytes, with a MIC of 8 mg/mL. The MeOH and CH2Cl2/CH3OH (1:1) root extracts showed the maximum activity against S. epidermidis with MIC values of 0.25 mg/mL. The strongest antibacterial effects were demonstrated against Staphylococcus epidermidis, which exhibited a 0.0625 mg/mL MIC for compound 1. The strongest radical scavenging activity was exhibited by the methanol extract (IC50 = 3.4 μg/mL), and compounds 4, 6, 5, 3, 7, and 2 with IC50 values of 3.2, 3.38, 3.6, 3.8, 4.2, and 4.7 μg/mL, respectively, in comparison with ascorbic acid (IC50 = 1.3 μg/mL). The results of the molecular docking analysis of compounds revealed minimal binding energies range from -38.5 to -43.1 kJ/mol, -33.1 to -42.7 kJ/mol, -34.7 to -39.3.7 kJ/mol, -25.5 to -37.6 kJ/mol against human myeloperoxidase (PDB ID: 1DNU), murA enzyme (PDB ID: 1UAE), human topoisomerase IIβ (PDB ID: 4fm9), S. epidermidis FtsZ (PDB number: 4M8I) proteins, respectively. The docking results and the in vitro antibacterial activity are in good agreement. These findings show that the isolated compounds 2-7 can act as potential antioxidants and strong antibacterials against Staphylococcus aureus and S. epidermidis. As a result, V. sinaiticum root extracts have the potential to be effective in treating diseases caused by bacteria and free radicals, as long as further investigation has been suggested for the ultimate decision of this plant's potential candidate.

Approaches for Stereotactic Radiosurgery (SRS)/Stereotactic Radiotherapy (SRT) in brain metastases using different radiotherapy modalities (Feasibility study)

BACKGROUND

SRS and SRT are precise treatments for brain metastases, delivering high doses while minimizing doses to nearby organs. Modern linear accelerators enable the precise delivery of SRS/SRT using different modalities like three-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), and Rapid Arc (RA).

OBJECTIVE

This study aims to compare dosimetric differences and evaluate the effectiveness of 3DCRT, IMRT, and Rapid Arc techniques in SRS/SRT for brain metastases.

METHODS

10 patients with brain metastases, 3 patients assigned for SRT, and 7 patients for SRS. For each patient, 3 treatment plans were generated using the Eclipse treatment planning system using different treatment modalities.

RESULTS

No statistically significant differences were observed among the three techniques in the homogeneity index (HI), maximum D2%, and minimum D98% doses for the target, with a p >  0.05. The RA demonstrated a better conformity index of 1.14±0.25 than both IMRT 1.21±0.26 and 3DCRT 1.37±0.31. 3DCRT and IMRT had lower Gradient Index values compared to RA, suggesting that they achieved a better dose gradient than RA. The mean treatment time decreased by 26.2% and 10.3% for 3DCRT and RA, respectively, compared to IMRT. In organs at risk, 3DCRT had lower maximum doses than IMRT and RA, but some differences were not statistically significant. However, in the brain stem and brain tissues, RA exhibited lower maximum doses compared to IMRT and 3DCRT. Additionally, RA and IMRT had lower V15Gy, V12Gy, and V9Gy values compared to 3DCRT.

CONCLUSION

While 3D-CRT delivered lower doses to organs at risk, RA and IMRT provided better conformity and target coverage. RA effectively controlled the maximum dose and irradiated volume of normal brain tissue. Overall, these findings indicate that 3DCRT, RA, and IMRT are suitable for treating brain metastases in SRS/SRT due to their improved dose conformity and target coverage while minimizing dose to healthy tissues.

Prodigiosin/celecoxib-loaded into zein/sodium caseinate nanoparticles as a potential therapy for triple negative breast cancer

Nowadays, breast cancer is considered one of the most upsetting malignancies among females. Encapsulation of celecoxib (CXB) and prodigiosin (PDG) into zein/sodium caseinate nanoparticles (NPs) produce homogenous and spherical nanoparticles with good encapsulation efficiencies (EE %) and bioavailability. In vitro cytotoxicity study conducted on human breast cancer MDA-MB-231 cell lines revealed that there was a significant decline in the IC50 for encapsulated drugs when compared to each drug alone or their free combination. In addition, results demonstrated that there is a synergism between CXB and PDG as their combination indices were 0.62251 and 0.15493, respectively. Moreover, results of scratch wound healing assay revealed enhanced antimigratory effect of free drugs and fabricated NPs in comparison to untreated cells. Furthermore, In vitro results manifested that formulated nanoparticles exhibited induction of apoptosis associated with reduced angiogenesis, proliferation, and inflammation. In conclusion, nanoencapsulation of multiple drugs into nanoparticles might be a promising approach to develop new therapies for the managing of triple negative breast cancer.

Analysis of Three Species of Cassipourea Traditionally Used for Hypermelanosis in Selected Provinces in South Africa

There is a growing demand and use of herbal cosmetics for skin purposes due to their perceived safety when applied to the skin. Three Cassipourea species commonly known as "ummemezi" are used interchangeably by women in rural areas of Eastern Cape and KwaZulu-Natal provinces to treat hypermelanosis as well as sun protection. We conducted a phytochemical comparison of three Cassipourea species; Cassipourea flanaganii (Schinz) Alston, Cassipourea gummiflua Tul. verticillata (N.E.Br.) J. Lewis and Cassipourea malosana (Baker) Alston by Liquid Chromatography-Mass Spectrometry (LC-MS/MS) analysis in negative mode. The results obtained from the LC-MS/MS yielded a total number of twenty-four compounds of different chemical classes, including fatty acids, steroids, di- and tri-terpenoids, flavonoids, phenolic acids, and eighteen among them were tentatively identified. The LC-MS /MS analysis showed that the three studied Cassipourea extracts contain compounds that have anti-tyrosinase activity and consequently. The presence of these compounds, either in synergy or individually, can be attributed to the anti-tyrosinase effect. Although the traditional names of the species are used interchangeably, they are different, however, they possess similar skin-lightening properties. Despite the recent popularity of modern cosmetic products, plants continue to play an important role in the local cosmetics industry in South Africa's Eastern Cape and KwaZulu-Natal community provinces.

Does the urinary microbiome profile change after treatment of bladder cancer?

INTRODUCTION

We sought to investigate the change in the urinary microbiome profile after transurethral resection of bladder tumor (TURBT).

METHODS

Urine specimens were collected from consecutive patients with bladder cancer. Patients were divided into those with bladder tumors ("Tumor group": de novo tumors or recurrent/progressed after TURBT ± intravesical therapy) versus those without evidence of recurrence after treatment "No Recurrent Tumor group". Samples were analyzed using 16S rRNA sequencing. Alteration in the urinary microbiome was described in terms of alpha (diversity within a sample measured by Observed, Chao, Shannon, and Simpson indices), beta diversities (diversity among different samples measured by Brady Curtis Diversity index), and differential abundance of bacteria at the genus level. Analyses were adjusted for gender, method of preservation (frozen vs preservative), and method of collection (mid-stream vs. catheter).

RESULTS

Sixty-eight samples were analyzed (42 in "Tumor" vs 26 in "No Recurrent Tumor" groups). The median age was 70 years (IQR 64-74) and 85% were males. All patients in the "No Recurrent Tumor" group had non-muscle invasive bladder cancer and 85% received BCG compared to 69% and 43% for the "Tumor" group, respectively. There was no significant difference in alpha diversity (p > 0.05). Beta diversity was significantly different (p = 0.04). Veillonella and Bifidobacterium were more abundant in the "Tumor" group (> 2FC, p = 0.0002), while Escherichia-Shigella (> 2FC, p = 0.0002) and Helococcus (> 2FC, p = 0.0008) were more abundant in the "No Recurrent Tumor" group.

CONCLUSION

Bladder cancer patients with no recurrence and/or progression exhibited a different urinary microbiome profile compared to those with tumors.

The impact of NCCN-compliant multidisciplinary conference on the uptake of active surveillance among eligible patients with localized prostate cancer

INTRODUCTION

We sought to investigate the impact of National Comprehensive Cancer Network (NCCN)-compliant multidisciplinary conference on the uptake of active surveillance (AS) among eligible patients with prostate cancer.

METHODS

Retrospective review of our AS database was performed. Patients who are eligible for AS who sought a second opinion at a comprehensive cancer center (2010-2021) were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Cochrane Armitage test was used to examine trends over time. Multivariable regression models were fit to evaluate variables associated with the receipt of AS.

RESULTS

Seven hundred twelve patients were identified (19% NCCN very low risk, 32% low risk, and 49% intermediate favorable risk). 43% were recommended AS as the preferred option by the community compared to 68% by LPCC, and 65% elected AS. Recommending AS significantly increased between 2010 and 2021 by the community (from 26% to 57%) and by LPCC (from 52% to 82%), while the proportion of men who received AS increased from 47% to 80% during the same period (P < 0.0001 for all). More recent LPCC era 2017 to 2021 (OR 12.31, 95% CI, 5.60-27.03, P < 0.0001), African American race (OR 0.42, 95% CI, 0.18-0.96, P = 0.04), positive cores at biopsy (OR 0.96, 95% CI, 0.94-0.97, P < 0.0001), age (OR 1.14, 95% CI, 1.10-1.18, P < 0.0001), NCCN low risk (OR 0.25, 95% CI, 0.08-0.81, P = 0.02) and NCCN intermediate favorable risk (OR 0.03, 95% CI, 0.01-0.09, P < 0.0001) were associated with receipt of AS.

CONCLUSION

AS recommendation increased significantly over time by community urologists and to a higher extent by NCCN-compliant multidisciplinary conference. The Uptake of AS significantly increased within the same period. More recent LPCC era 2017 to 2021, African American race, the proportion of positive cores at biopsy, age, and NCCN risk were the main determinants of receipt of AS.

Development and validation of nomogram to improve the specificity of multiparametric MRI for clinically significant prostate cancer

OBJECTIVE

To develop and validate a nomogram to improve the specificity of prostate imaging reporting and data system (PI-RADS) on multiparametric magnetic resonance imaging (MRI) for clinically significant prostate cancer on targeted fusion biopsy.

METHODS

A retrospective review of patients who underwent fusion biopsy for PI-RADS 3-5 lesions using UroNav and Artemis systems between 2016 and 2022 was performed. Patients were divided into those with CS disease on fusion biopsy (Gleason grade group ≥2) versus those without. Multivariable analysis was used to identify variables associated with CS disease. A 100-point nomogram was constructed, and ROC curve was generated.

RESULTS

1485 lesions (1032 patients) were identified, 510 (34%) were PI-RADS 3, 586 (40%) were PI-RADS 4, and 389 (26%) were PI-RADS 5. Of these, 11% of PI-RADS 3, 39% of PI-RADS 4, and 61% of PI-RADS 5 showed CS disease. CS disease was associated with older age (OR 1.04, 95% CI 1.02-1.06, p < 0.01), previous negative biopsy (OR 0.52, 95% CI 0.36-0.74, p < 0.01), presence of multiple PI-RADS 3-5 lesions (OR 0.61, 95% CI 0.45-0.83, p < 0.01), peripheral zone location (OR 1.88, 95% CI 1.30-2.70, p < 0.01), PSA density (OR 1.48 per 0.1 unit, 95% CI 1.33-1.64, p < 0.01), PI-RADS score 4 (OR 3.28, 95% CI 2.21-4.87, p < 0.01), and PI-RADS score 5 (OR 7.65, 95% CI 4.93-11.85, p < 0.01). Area under ROC curve was 82% for nomogram compared to 75% for PI-RADS score alone.

CONCLUSION

We report a nomogram that combines PI-RADS score with other clinical parameters. The nomogram outperforms PI-RADS score for the detection of CS prostate cancer.

Does testosterone replacement therapy increase the risk of conversion to treatment in patients with prostate cancer on active surveillance?

PURPOSE

We aimed to evaluate the impact of testosterone replacement therapy (TRT) in patients with localized prostate cancer (CaP) who elected active surveillance (AS).

METHODS

A retrospective review of our CaP database was performed. Patients who received TRT while on AS were identified and were matched to a cohort of patient on AS while not on TRT (1:3) using propensity score matching. Treatment-free survival (TFS) was computed using Kaplan Meier method. Multivariable Cox regression model was used to evaluate variables associated with treatment.

RESULTS

Twenty-four patients in the TRT group were matched to 72 patients without TRT. Median follow-up was 5.82 years (IQR 3.27-9.30). There was no significant difference in conversion to treatment (24% vs. 21%, P = 1.00) There was no significant difference in TFS (log rank P = 0.87). Prostate specific antigen (PSA) density was the only variable associated TFS (HR 1.08, 95%CI 1.03-1.13, P = 0.001).

CONCLUSION

TRT was not associated with conversion to treatment in this matched analysis among patients with localized prostate cancer on AS.

Prodigiosin-Functionalized Probiotic Ghosts as a Bioinspired Combination Against Colorectal Cancer Cells

Lactobacillus acidophilus ghosts (LAGs) with the unique safety of a probiotic, inherent tropism for colon cells, and multiple bioactivities offer promise as drug carriers for colon targeting. Our objective was to evaluate LAGs functionalized with prodigiosin (PG), apoptotic secondary bacterial metabolite, as a bioinspired formulation against colorectal cancer (CRC). LAGs were prepared by a chemical method and highly purified by density gradient centrifugation. LAGs were characterized by microscopic and staining techniques as relatively small-sized uniform vesicles (≈1.6 µm), nearly devoid of cytoplasmic and genetic materials and having a negatively charged intact envelope. PG was highly bound to LAGs envelope, generating a physiologically stable bioactive entity (PG-LAGs), as verified by multiple microscopic techniques and lack of PG release under physiological conditions. PG-LAGs were active against HCT116 CRC cells at both the cellular and molecular levels. Cell viability data highlighted the cytotoxicity of PG and LAGs and LAGs-induced enhancement of PG selectivity for HCT116 cells, anticipating dose reduction for PG and LAGs. Molecularly, expression of the apoptotic caspase 3 and P53 biomarkers in HCT116 intracellular proteins was significantly upregulated while that of the anti-apoptotic Bcl-2 (B-cell lymphoma 2) was downregulated by PG-LAGs relative to PG and 5-fluorouracil. PG-LAGs provide a novel bacteria-based combination for anticancer biomedicine.

Methoxylated Flavonols and ent-Kaurane Diterpenes from the South African Helichrysum rutilans and Their Cosmetic Potential

Chromatographic fractionation of a methanol extract of Helichrysum rutilans afforded seven known compounds. The isolated compounds were identified as 5,7,8-trihydroxy-3,6-dimethoxyflavone-8-O-2-methyl-2-butanoate (C-1), 5,7-dihydroxy-3,6,8-trimethoxyflavone (C-2), 5-hydroxy-3,6,7,8-tetramethoxyflavone (C-3), 5-hydroxy-3,6,7-trimethoxyflavone (C-4), ent-kaurenoic acid (C-5), ent-kauran-18-al (C-6), and 15-α-hydroxy-(-)-ent-kaur-16-en-19-oic acid (C-7). Compounds C-1-C-4 demonstrated high antioxidant capacities on ORAC hydroxyl radical (2.114 ± 4.01; 2.413 ± 6.20; 1.924 ± 16.40; 1.917 ± 3.91) × 106; ORAC peroxyl radical (3.523 ± 3.22; 2.935 ± 0.13; 2.431 ± 8.63; 2.814 ± 5.20) × 103 µMTE/g; and FRAP (1251.45 ± 4.18; 1402.62 ± 5.77) µMAAE/g, respectively. Moderate inhibitory activities against Fe2+-induced lipid peroxidation were observed for C-1-C-4 as IC50 values of 13.123 ± 0.34, 16.421 ± 0.92, 11.64 ± 1.72, 14.90 ± 0.06 µg/mL, respectively, while their respective anti-tyrosinase activities with IC50 values of 25.735 ± 9.62, 24.062 ± 0.61, 39.03 ± 13.12, 37.67 ± 0.98 µg/mL were also observed. All compounds demonstrated TEAC values within the range of 1105-1424 µMTE/g. The result is an indication that a methanol extract of H. rutilans might possibly be a good source of natural antioxidants against ailments caused by cellular oxidative stress and as inhibitors against skin depigmentation, as well as possible raw materials needed for slowing down perishable agricultural products. This is the first report on the phytochemical and biological evaluation of H. rutilans.

Green-Synthesized Silver Nanoparticles: Antifungal and Cytotoxic Potential for Further Dental Applications

Fungal infections caused by Candida albicans (C. albicans) are one of the most prevalent types of oral disorders in the elderly. It has been reported that drug resistance to fungal pathogens poses a severe risk to global healthcare systems and public health. Therefore, the goal of this work is to investigate the cytotoxic and antifungal properties of silver nanoparticles (AgNPs) produced using three different natural extracts: Berzelia lanuginose, Helichrysum cymosum, and Searsia crenata. According to the UV-Vis results, the synthesized AgNPs via B. lanuginose, H. cymosum, and S. crenata show surface plasmonic resonance (SPR) peaks at 430, 440, and 428 nm, respectively. HR-TEM revealed different shapes for the nanoparticles within the size ranges of 16-20, 31-60, and 57-72 nm for B. lanuginose, H. cymosum, and S. crenata, respectively. Using a human oral fibroblast cell line, the cytotoxicity of both AgNPs and plant extracts was tested at concentrations of 0.007, 0.012, 0.025, and 0.062 mg/mL (buccal mucosa fibroblasts). The antifungal activity showed growth inhibition zones of approximately 18 mm, 18.67 mm, and 18.33 mm for the AgNPs conjugated with B. lanuginose, H. cymosum, and S. crenata, respectively. For the studied samples, the minimum inhibitory concentration (MIC₅₀) was less than 0.015 mg/mL. The AgNPs exhibited antifungal activity that was concentration- and size-dependent. The results of this study offer new insights into the cytotoxicity and antifungal activity of the green-synthesized AgNPs.

An Investigation into the Acute and Subacute Toxicity of Extracts of Cassipourea flanaganii Stem Bark In Vivo

The conventional use of medicinal plants is in part based on the widespread belief that plant crude extracts are non-toxic. In South Africa, traditional preparations of Cassipourea flanaganii used to treat hypermelanosis have accordingly been regarded by many as non-toxic. Whether that is so impacts on the potential of bark extracts to be developed as a commercial drug to treathypermelanosis, given their documented capacity to inhibit tyrosinase activity. Our study investigated the acute and subacute toxicity of the methanol extract of C. flanaganii bark in rats. Wistar rats were randomly assigned into different treatment groups. The rats received a daily oral gavage of crude extract for acute and subacute toxicity tests. Haematological, biomechanical, clinical and histopathology examinations were carried out to evaluate the possible toxicity of C. flanaganii. The results were subjected to the Student's t-test and ANOVA. For both acute and subacute toxicity, there was no statistical difference between the groups. There were no clinical or behavioral signs of toxicity observed in the rats. No treatment-related gross pathology lesions and no histopathology were observed. The findings of this study demonstrate the absence of acute or subacute toxicity after oral treatment with C. flanaganii stem bark extracts in Wistar rats at the levels administered. Chemical profiling of the total extract using LC-MS tentatively identified eleven (11) compounds as the major chemical constituents.

Carbon dots labeled Lactiplantibacillus plantarum: a fluorescent multifunctional biocarrier for anticancer drug delivery

A carbon dots (CDs)-biolabeled heat-inactivated Lactiplantibacillus plantarum (HILP) hybrid was investigated as a multifunctional probiotic drug carrier with bioimaging properties using prodigiosin (PG) as anticancer agent. HILP, CDs and PG were prepared and characterized using standard methods. CDs-labeled HILP (CDs/HILP) and PG loaded CDs/HILP were characterized by transmission electron microscopy (TEM), laser scanning confocal microscopy (LSCM) and for entrapment efficiency (EE%) of CDs and PG, respectively. PG-CDs/HILP was examined for stability and PG release. the anticancer activity of PG-CDs/HILP was assessed using different methods. CDs imparted green fluorescence to HILP cells and induced their aggregation. HILP internalized CDs via membrane proteins, forming a biostructure with retained fluorescence in PBS for 3 months at 4°C. Loading PG into CDs/HILP generated a stable green/red bicolor fluorescent combination permitting tracking of both drug carrier and cargo. Cytotoxicity assay using Caco-2 and A549 cells revealed enhanced PG activity by CDs/HILP. LCSM imaging of PG-CDs/HILP-treated Caco-2 cells demonstrated improved cytoplasmic and nuclear distribution of PG and nuclear delivery of CDs. CDs/HILP promoted PG-induced late apoptosis of Caco-2 cells and reduced their migratory ability as affirmed by flow cytometry and scratch assay, respectively. Molecular docking indicated PG interaction with mitogenic molecules involved in cell proliferation and growth regulation. Thus, CDs/HILP offers great promise as an innovative multifunctional nanobiotechnological biocarrier for anticancer drug delivery. This hybrid delivery vehicle merges the physiological activity, cytocompatibility, biotargetability and sustainability of probiotics and the bioimaging and therapeutic potential of CDs.

Impact of an NCCN-Compliant Multidisciplinary Conference on Treatment Decisions for Localized Prostate Cancer

BACKGROUND

We sought to investigate the impact of an NCCN-compliant multidisciplinary conference on treatment decisions of patients with localized prostate cancer.

METHODS

A retrospective review of our quality assurance localized prostate cancer database was performed. All patients with localized prostate cancer who sought a second opinion at Roswell Park Comprehensive Cancer Center between 2009 and 2019 were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Multivariable regression models were fit to evaluate variables associated with concordance between community recommendations, LPCC recommendations, and treatment received by patients.

RESULTS

A total of 1,164 patients were identified, of whom 26% had NCCN very low-/low-risk, 27% had favorable intermediate-risk, 25% had unfavorable intermediate-risk, and 22% had high-/very high-risk prostate cancer. Pathology changed in 11% of patients after genitourinary pathologist review, which caused disease reclassification in 9%. Concordance between community and LPCC recommendations occurred in 78%, with lowest concordance for androgen deprivation therapy (21%) and radiotherapy (53%). Concordance between community recommendations and treatment received occurred in 65%, with lowest concordance for androgen deprivation therapy and radiotherapy; among those who were recommended radiotherapy as the only option by their community urologist, only 26% received it. Concordance between LPCC recommendations and treatment received occurred in 92%.

CONCLUSIONS

Community recommendations differed from the multidisciplinary NCCN-compliant recommendations in 22% of patients, primarily for radiotherapy. Multidisciplinary recommendations matched the treatment received in 92% of patients compared with 65% for community recommendations.

Development of a predictive model for recurrence-free survival in pTa low-grade bladder cancer

BACKGROUND

Data on Ta low-grade (LG) non-muscle invasive bladder cancer (NMIBC) have shown that follow-up cystoscopies are normal in 82% and 67% of patients with single and multiple tumors, respectively.

OBJECTIVE

To develop a predictive model associated with recurrence-free survival (RFS) at 6, 12, 18 and 24 months in TaLG cases that consider the patients' risk aversion.

MATERIALS AND METHODS

Data from a prospectively maintained database of 202 newly diagnosed TaLG NMIBC patients treated at Scandinavian institutions were used for the analysis. To identify risk groups associated with recurrence, we performed a classification tree analysis. Association between risk groups and RFS was evaluated by Kaplan Meier analysis. A Cox proportional hazard model selected significant risk factors associated with RFS using the variables defining the risk groups. The reported C index for the Cox model was 0.7. The model was internally validated and calibrated using 1000 bootstrapped samples. A nomogram to estimate RFS at 6, 12, 18, and 24 months was generated. The performance of our model was compared to EUA/AUA stratification using a decision curve analysis (DCA).

RESULTS

The tree classification found that tumor number, tumor size and age were the most relevant variables associated with recurrence. The patients with the worst RFS were those with multifocal or single, ≥ 4cm tumors. All the relevant variables identified by the classification tree were significantly associated with RFS in the Cox proportional hazard model. DCA analysis showed that our model outperformed EUA/AUA stratification and the treat all/none approaches.

CONCLUSION

We developed a predictive model to identify TaLG patients that benefit from less frequent follow-up cystoscopy schedule based on the estimated RFS and personal recurrence risk aversion.

Analysis of Complications After Robot-Assisted Radical Cystectomy Between 2002-2021

OBJECTIVE

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications.  Cochran-Armitage trend test was used to describe the trend of complications over time.

RESULTS

1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P < .01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P < .01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P < .01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P < .01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P < .01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P < .01) were associated with high-grade complications.

CONCLUSION

Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Phytochemical Investigation and Biological Studies on Selected Searsia Species

Searsia is the more recent name for the genus Rhus, which contains over 250 individual species of flowering plants in the family Anacardiaceae. Several Searsia species are used in folk medicine and have been reported to exhibit various biological activities. Although known to exhibit different terpenoids and flavonoids, the chemistry of the Searsia genus is not comprehensively studied due to the structural complexity of the compounds. In this study, the extraction, isolation, and identification of secondary metabolites from three Searsia species (Searsia glauca, S. lucida, and S. laevigata) were conducted using chromatographic and spectroscopic techniques and afforded five known terpenes, viz., moronic acid (1), 21β-hydroxylolean-12-en-3-one (2), lupeol (11), α-amyrin (9), and β-amyrin (10), in addition to six known flavonoids, myricetin-3-O-β-galactopyranoside (3), rutin (4), quercetin (5), apigenin (6), amentoflavone (7), and quercetin-3-O-β-glucoside (8). The structural elucidation of the isolated compounds was determined based on NMR (1D and 2D) and comparison with the data in the literature. Biological assays, such as antioxidant and enzyme inhibition activity assays, were conducted on the plant extracts and the isolated compounds. The antioxidant capacities of hexane, dichloromethane, ethyl acetate, methanol, and butanol main extracts were investigated using ferric ion reducing power (FRAP), oxygen radical absorbance capacity (ORAC), and Trolox equivalent antioxidant capacity (TEAC) assays. The results showed high antioxidant activities for methanol and butanol extracts of the three plants. The isolated compounds were tested against alpha-glucosidase and alpha-amylase, and the results showed the potent activity of moronic acid (C1) (IC₅₀ 10.62 ± 0.89 and 20.08 ± 0.56 µg/mL, respectively) and amentoflavone (C7) (IC₅₀ 5.57 ± 1.12 µg/mL and 19.84 ± 1.33 µg/mL, respectively). Isolated compounds of and biological assays for S. glauca, S. lucida, and S. laevigata are reported for the first time.

Chemical Study and Comparison of the Biological Activities of the Essential Oils of Helichrysum petiolare, H. cymosum, and H. odoratissimum

Helichrysum species are prominent South African medicinal plants. From the essential oils (EOs) of three Helichrysum species, H. petiolare, H. odoratissimum, and H. cymosum, sixty-three constituent components were identified, with hydrocarbons and oxygenated monoterpenes and sesquiterpenes as major components. The compounds were analyzed by gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance (NMR) spectroscopy. In H. petiolare EO, the major components were faurinone (20.66%) and (E)-β-ocimene (17.21%). Faurinone was isolated from this EO for the first time. In H. odoratissimum, 1,8-cineole (17.44%) and α-pinene, and γ-curcumene (15.76%) were the major components whereas, in H. cymosum, α-pinene (29.82%) and (E)-caryophyllene (19.20%) were the major components. In the antibacterial activity study, the EOs were tested against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. The EOs were found to possess low antibacterial, anti-tyrosinase, and photoprotection activities and moderate antioxidant capacities, thus establishing these Helichrysum EOs as valuable antioxidant agents.

Uretero-enteric Strictures after Robot Assisted Radical Cystectomy: Prevalence and Management Over Two Decades

INTRODUCTION

To evaluate the prevalence, predictors, management, and trends for ureteroenteric strictures (UES) after robot-assisted radical cystectomy (RARC).

METHODS

Retrospective review of our RARC database was performed (2005-2022). UES was described in terms of timing, laterality, and management. Kaplan-Meier curves were used to depict time to UES. Local regression was used to assess trend of UES over time and multivariable regression to identify variables associated with UES.

RESULTS

UES occurred in 109 patients (15%). UES occurred in 13%, 17%, and 19% at 1, 3, and 5 years after RARC, respectively. Incidence of UES decreased in 2017, coinciding with stentless uretero-enteric anastomosis. UES occurred on the right in 33%, on the left in 46%, and bilaterally in 21%. All patients were initially managed by nephrostomy/stent. Surgical revision was required in 45% of patients, of which 13% developed recurrent UES after revision. On MVA, UES formation was associated with ureteral stents (OR 2.27, 95%CI 1.01-5.10, P = .05) and receipt of neoadjuvant chemotherapy (OR 2.01, 95%CI 1.24-3.25, P = .005).

CONCLUSION

UES occurred in 15% of patients after RARC, with 45% of patients requiring surgical reimplantation. Ureteral stents and the receipt of neoadjuvant chemotherapy were associated with UES formation.

Characterization of Four New Compounds from Protea cynaroides Leaves and Their Tyrosinase Inhibitory Potential

Protea cynaroides (king protea) is a flowering plant that belongs to the Proteaceae family. This multi-stemmed shrub is the national flower of South Africa and has important economic and medicinal values. Traditionally, the main therapeutic benefits of this plant species include the treatment of cancer, bladder, and kidney ailments. There are very limited reports on the isolation of phytochemicals and their biological evaluation from P. cynaroides. In this study, the leaves of P. cynaroides were air-dried at room temperature, powdered, and extracted with 80% methanol followed by solvent fractionation (hexane, dichloromethane, ethyl acetate, and butanol). The ethyl acetate and butanol extracts were chromatographed and afforded four new (1–4) and four known (5–8) compounds, whose structures were characterized accordingly as 3,4-bis(4-hydroxybenzoyl)-1,5-anhydro-D-glucitol (1), 4-hydroxybenzoyl-1,5-anhydro-D-glucitol (2), 2-(hydroxymethyl)-4-oxo-4H-pyran-3-yl-6-O-benzoate-β-D-glucopyranoside (3), 3-hydroxy-7,8-dihydro-β-ionone 3-O-β-D-glucopyranoside (4), 4-hydroxybenzoic acid (5), 1,5-anhydro-D-glucitol (6), 3,4-dihydroxybenzoic acid (7), and 3-hydroxykojic acid (8). The structural elucidation of the isolated compounds was determined based on 1D and 2D NMR, FTIR, and HRMS spectroscopy, as well as compared with the available literature data. The tyrosinase inhibitory activities of the extracts and isolated compounds were also determined. According to the results, compounds 7 and 8 exhibited potent competitive tyrosinase inhibitory activity against L-tyrosine substrates with IC₅₀ values of 0.8776 ± 0.012 and 0.7215 ± 0.090 µg/mL compared to the control (kojic acid, IC₅₀ = 0.8347 ± 0.093), respectively. This study is the first chemical investigation of compounds 1–4 from a natural source and the first report of the biological evaluation of compounds 1–5 against the tyrosinase enzyme. The potent anti-tyrosinase activity exhibited by P. cynaroides constituents will support future exploration of the plant in the cosmetic field upon further biological and clinical investigations.

Transition from da Vinci to Versius robotic surgical system: initial experience and outcomes of over 100 consecutive procedures

We sought to describe the development of the robotic urology program at Sindh Institute of Urology and Transplantation (SIUT) and the feasibility of transitioning from the da Vinci to Versius robotic systems. The SIUT robotics program began in 2017 utilizing the da Vinci Si robotic system, transitioning to the Versius system in 2021. Retrospective review of our quality assurance database was performed. All procedures performed utilizing the two systems were identified, analyzed, and compared. Data were described with descriptive statistics. Matched procedures (by type of procedure) performed by the same surgeons utilizing the da Vinci and Versius were compared. All tests were double-sided with statistical significance set at p < 0.05.106 cases were performed by the Versius robotic surgical system in 2021. Median age was 42 years (IQR 26-56), and 69 (65%) were males. Procedures included both benign (83%) and malignant disorders (17%), several upper tract (75%), and pelvic/lower tract (25%). No major intraoperative complications were observed. Conversion to open occurred in six procedures. Malfunction of the robotic arms occurred in two procedures: the erroneous bedside units (BSU) were replaced. Eight patients developed postoperative high-grade complications. Matched analysis of various procedures (pyeloplasty, stone surgery, radical, partial, and simple nephrectomy) showed no significant difference in perioperative outcomes. To our knowledge, this is the first and largest series of urologic procedures performed by the Versius robotic surgical system.

Relapses Rates and Patterns for Pathological T0 After Robot-Assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

OBJECTIVES

To investigate the oncologic outcomes of pT0 after robot-assisted radical cystectomy (RARC).

METHODS

A retrospective review of the International Robotic Cystectomy Consortium database was performed. Patients with pT0 after RARC were identified and analyzed. Data were reviewed for demographics and pathologic outcomes. Kaplan-Meier curves were used to depict recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS). Multivariate stepwise Cox regression models were used to identify variables associated with RFS and OS.

RESULTS

Four hundred seventy-one patients (18%) with pT0 were identified. Median age was 68 years (interquartile range (IQR) 60-73), with a median follow up of 20 months (IQR 6-47). Thirty-seven percent received neoadjuvant chemotherapy and 5% had pN+ disease. Seven percent of patients experienced disease relapse; 3% had local and 5% had distant recurrence. Most common sites of local and distant recurrences were pelvis (1%) and lungs (2%). Five-year RFS, DSS, and OS were 88%, 93%, and 79%, respectively. Age (hazards ratio [HR] 1.05, 95% confidence interval [CI] 1.01-1.09, P = 0.02), pN+ve (HR 11.48, 95% CI 4.47-29.49, P < .01), and reoperations within 30 days (HR 5.53, 95% CI 2.08-14.64, P < .01) were associated with RFS. Chronic kidney disease (HR 3.24, 95% CI 1.45-7.23, P < .01), neoadjuvant chemotherapy (HR 0.41, 95% CI 0.18-0.92, P = .03), pN+ve (HR 4.37, 95% CI 1.46-13.06, P < .01), and reoperations within 30 days (HR 2.64, 95% CI, 1.08-6.43, P = .03) were associated with OS.

CONCLUSIONS

Despite pT0 status at RARC, 5% had pN+ disease and 7% of patients relapsed. Node status was the variable strongest associated with RFS and OS in pT0.

Alpha-Glucosidase and Alpha-Amylase Inhibitory Activities, Molecular Docking, and Antioxidant Capacities of Plectranthus ecklonii Constituents

Shortage in insulin secretion or degradation of produced insulin is the principal characteristic of the metabolic disorder of diabetes mellitus (DM). However, because the current medications for the treatment of DM have many detrimental side effects, it is necessary to develop more effective antidiabetic drugs with minimal side effects. Alpha-glucosidase and alpha-amylase inhibitors are directly implicated in the delay of carbohydrate digestion. Pharmacologically, these inhibitors could be targeted for the reduction in glucose absorption rate and, subsequently, decreasing the postprandial rise in plasma glucose and the risk for long-term diabetes complications. The main objectives of this research study were to isolate different phytochemical constituents present in the methanolic extract of Plectranthusecklonii and evaluate their alpha-glucosidase and alpha-amylase inhibitory activities and antioxidant capacity. The phytochemical investigation of the methanolic extract of P. ecklonii yielded three known compounds, viz. parvifloron D, F, and G (1–3, respectively). Parvifloron G was isolated for the first time from P. ecklonii. The in vitro bio-evaluation of the methanolic extract of P. ecklonii and its isolated compounds against alpha-glucosidase showed that 3 exhibited moderate inhibitory activity with IC50 values of 41.3 ± 1.2 μg/mL. Molecular docking analysis confirmed the alpha-glucosidase inhibitory activity demonstrated by 3. Additionally, strong antioxidant capacities were demonstrated by 3 and 1 on ORAC (28726.1 ± 8.1; 3942.9.6.6 ± 0.1 µM TE/g), respectively, which were comparable with the reference antioxidant epigallocatechingallate (EGCG). Furthermore, 3 also showed strong activity on TEAC (3526.1 ± 0.6 µM TE/g), followed by 2 (1069.3 ± 2.4 µM TE/g), as well as on FRAP (1455.4 ± 2.0 µM AAE/g). The methanolic extract of P. ecklonii is a rich source of abietane diterpenes with strong antioxidant activities. This is the first scientific report on alpha-glucosidase and alpha-amylase inhibitory activities, molecular docking, and antioxidant capacities of P. ecklonii constituents.

Polyphenolic profile and ethno pharmacological activities of Callistemonsubulatus (Cheel) Craven leaves cultivated in Egypt

ETHNOPHARMACOLOGICAL RELEVANCE

The genus Callistemon (syn. Melaleuca) of the myrtle family (Myrtaceae) has been documented as an integral part in the ethnobotanical system of the indigenous people of Australian mainland and many of its islands. Several Callistemons including the species subulatus were used by aboriginal Australians for making rafts, roofs for shelters, bandages, and food recipes, in addition to the management of wounds, infections, pain, cough, bronchitis, and gastrointestinal tract (GIT) disorders.

AIM OF THE STUDY

The current study is designed to document the therapeutic effect of the aqueous methanolic extract (AME) of C. sabulatus Chell (syn. M. sabulata) leaves in the management of diarrhea and pain. Also, its influence on additional pharmacological modalities that are related to oxidative stress just as skin aging. Ultimately, the polyphenolic profile of the extract is disclosed and correlated to the aforementioned bioactivities.

MATERIALS AND METHODS

The extract was fractionated using various chromatography techniques and the structures of the isolated compounds were determined based on their chemical and spectral data. The antioxidant activity was assessed using multiple models, including 2,2-diphenyl-picrylhydrazyl (DPPH), oxygen radical absorbance capacity (ORAC) and β-carotene bleaching assays. The anti-skin aging effect was evaluated using different relevant enzymatic assays. The antinociceptive activity was investigated using acetic acid-induced writhing, hot plate test, and formalin-induced paw licking in mice models. The antidiarrheal activity was gauge using the castor oil induced diarrhea, enter pooling and gastrointestinal motility in vivo models.

RESULTS

Diverse polyphenols, including quercetin-3-O-β-D-glucuronopyranoside (1), kaempferol-3-O-β-D-glucuronopyranoside (2), strictinin (3), quercetin-3-O-(2``-O-galloyl)-β-D-glucuronopyranoside (4), afzelin (5), di-galloyl glucose (6), mono-galloyl glucose (7), acacetin (8), apigenin-6,7-dimethyl ether (9), kaempferol trimethyl ether (10), dimethoxy chrysin (11), quercetin (12), kaempferol (13), methyl gallate (14), and gallic acid (15) were identified. The extract exhibited as significant antioxidant activity even better than that of Trolox or BHT. Moreover, it exerts elastase, tyrosinase, and collagenase inhibition activities, in addition to the significant peripheral and central analgesic activity in a dose-dependent manner (P < 0.0001). In castor oil induced diarrhea model, AME significantly prolonged the diarrhea onset, decreased the frequency of defecation, and weight of feces. Likewise, it exhibited a significant reduction in the gastrointestinal motility in charcoal meal model (P < 0.0001) and a considerable inhibitory effect on gastrointestinal transit and peristaltic index with all investigated doses (P < 0.0001).

CONCLUSION

Ethnobotanicals are versatile resources for the management of various ailments by indigenous people and the experimental research is utmost to validate and uncover their pharmacological relevance. C. sabulatus leaves have strong antioxidant, analgesic, anti-skin aging, and antidiarrheal activities which are validated for the first time by various in vitro and in vivo models. The metabolic profile of the unprecedented AME of C. sabulatus leaves compromises a wide array of bioactive polyphenolic metabolites including, flavonoids, tannins, and phenolic acids that are correlated to the observed bioactivities. Altogether, ethnobotanicals with high and diverse contents of polyphenols are potential candidates for the management of various human aliments including neuropathies, GIT disorders, and skin aging conditions.

Reference values for penile and clitoral lengths of healthy term Egyptian newborn infants

AIM

Examination of the external genital organs is an integral part of the routine physical examination of the newborn. Early recognition of micropenis or clitoromegaly is important as they may be the only obvious manifestation of pituitary or hypothalamic hormonal deficiencies at birth. Studies suggest that differences in penile or clitoral anthropometry may exist between different populations. Therefore, reference values for genital organs dimensions should be available and well known to medical personnel. We aim to establish reference values for the penile length in Egyptian newborn boys and reference values for the clitoral length in Egyptian newborn girls and to define micropenis and clitoromegaly according to Egyptian reference values.

METHODS

A total of 500 healthy term newborn boys and 500 healthy term newborn girls were enrolled in the study. Stretched penile length and clitoral length were measured during the first 7 days of postnatal life. Birth weight, length and head circumference were measured and recorded.

RESULTS

The mean (±SD) stretched penile length was 3.16 ± 0.41 cm. The mean (±SD) clitoral length was 0.51 ± 0.13. There was no significant correlation between penile or clitoral length, and body weight, length or head circumference.

CONCLUSION

Our study provides reference values for normal penile length and clitoral length in Egyptian newborns. Our study suggests that among healthy term Egyptian newborns, penile length of less than 2.13 cm may be considered micropenis and clitoral length of more than 0.83 cm may be considered clitoromegaly.

OUP accepted manuscript

STUDY QUESTION

What is the scope of literature regarding women’s reproductive span in terms of definitions, trends and determinants?

SUMMARY ANSWER

The scoping review found a wide variation in definitions, trends and determinants of biological, social and effective women’s reproductive span.

WHAT IS KNOWN ALREADY

A woman’s reproductive span refers to her childbearing years. Its span influences a woman’s reproductive decisions.

STUDY DESIGN, SIZE, DURATION

A systematic scoping review was conducted. We searched MEDLINE, PubMed, JSTOR, CINAHL, Web of Science and Scopus electronic databases from inception to January 2021 without imposing language or date restrictions. We searched unpublished sources including the Global Burden of Disease, Demographic and Health Surveys, and National Health and Nutrition Examination Surveys. The list of relevant references was searched by hand. Sixty-seven reports on women’s reproductive span were included in this review.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This scoping systematic review followed an established framework. The reporting of this scoping review followed the reporting requirements provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Extension for Scoping Reviews. Identified records were independently screened and data were extracted. We performed conceptual synthesis by grouping the studies by available concepts of reproductive span and then summarized definitions, measures used, temporal trends, determinants, and broad findings of implications on population demographics and assisted reproduction. Structured tabulation and graphical synthesis were used to show patterns in the data and convey detailed information efficiently, along with a narrative commentary.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 67 relevant reports on women’s reproductive span were published between 1980 and 2020 from 74 countries. Most reports (42/67) were cross-sectional in design. Literature on reproductive span was conceptually grouped as biological (the interval between age at menarche and age at menopause), effective (when a woman is both fertile and engaging in sexual activity) and social (period of exposure to sexual activity). We summarized the working definitions, trends and determinants of each concept. Few articles addressed implications on demographics and assisted reproduction.

LIMITATIONS, REASONS FOR CAUTION

A formal assessment of methodological quality of the included studies was not performed because the aim of this review was to provide an overview of the existing evidence base regardless of quality.

WIDER IMPLICATIONS OF THE FINDINGS

The review produced a comprehensive set of possible definitions of women’s reproductive span, trends, and potential determinants. Further advancement of these findings will involve collaboration with relevant stakeholders to rate the importance of each definition in relation to demography and fertility care, outline a set of core definitions, identify implications for policy, practice or research and define future research opportunities to explore linkages between reproductive spans, their determinants, and the need for assisted reproduction.

STUDY FUNDING/COMPETING INTEREST(S)

This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors had no competing interests.

STUDY REGISTRATION NUMBER

N/A.

Development and Validation of an Objective Scoring Tool for Robot-Assisted Partial Nephrectomy: Scoring for Partial Nephrectomy

Objective: To develop a structured and objective scoring tool for assessment of robot-assisted partial nephrectomy (RAPN): Scoring for Partial Nephrectomy (SPaN). Materials and Methods: Content development: RAPN was deconstructed into 6 domains by a multi-institutional panel of 10 expert robotic surgeons. Performance on each domain was represented on a Likert scale of 1 to 5, with specific descriptions of anchors 1, 3, and 5. Content validation: The Delphi methodology was utilized to achieve consensus about the description of each anchor for each domain in terms of appropriateness of the skill assessed, objectiveness, clarity, and unambiguous wording. The content validity index (CVI) of ≥0.75 was set as cutoff for consensus. Reliability: 15 de-identified videos of RAPN were utilized to determine the inter-rater reliability using linearly weighted percent agreement, and Construct validation of SPaN was described in terms of median scores and odds ratios. Results: The expert panel reached consensus (CVI ≥0.75) after 2 rounds. Consensus was achieved for 36 (67%) statements in the first round and 18 (33%) after the second round. The final six-domain SPaN included Exposure of the kidney; Identification and dissection of the ureter and gonadal vessels; Dissection of the hilum; Tumor localization and exposure; Clamping and tumor resection; and Renorrhaphy. The linearly weighted percent agreement was >0.75 for all domains. There was no difference between median scores for any domain between attendings and trainees. Conclusion: Despite the lack of significant construct validity, SPaN is a structured, reliable, and procedure-specific tool that can objectively assesses technical proficiency for RAPN.

Impact of neoadjuvant chemotherapy on survival and recurrence patterns after robot-assisted radical cystectomy for muscle-invasive bladder cancer: Results from the International Robotic Cystectomy Consortium

OBJECTIVES

To analyze the impact of neoadjuvant chemotherapy on survival and recurrence patterns in muscle-invasive bladder cancer after robot-assisted radical cystectomy.

MATERIALS AND METHODS

The International Robotic Cystectomy Consortium database was reviewed to identify patients who underwent robot-assisted radical cystectomy for muscle-invasive bladder cancer between 2002 and 2019. Survival outcomes, response rates, and recurrence patterns were compared between patients who received neoadjuvant chemotherapy and those who did not. Survival distributions were estimated using Kaplan-Meier analyses and compared using the log-rank test.

RESULTS

A total of 1370 patients with muscle-invasive bladder cancer were identified, of whom 353 (26%) received neoadjuvant chemotherapy. After a median follow-up of 27 months, neoadjuvant chemotherapy recipients had higher 3-year overall survival (74% vs 57%; log-rank P < 0.01), 3-year cancer-specific survival (83% vs 73%; log-rank P = 0.03), and 3-year relapse-free survival (64% vs 48%; log-rank P < 0.01). Neoadjuvant chemotherapy was a predictor of higher overall survival, cancer-specific survival, and relapse-free survival in univariate but not multivariate analysis. Pathological downstaging (46% vs 23%; P < 0.01), complete responses (24% vs 8%; P < 0.01), and margin negativity (95% vs 91%; P < 0.01) at robot-assisted radical cystectomy were more common in the neoadjuvant chemotherapy group. Neoadjuvant chemotherapy recipients had lower distant (15% vs 22%; P < 0.01) but similar locoregional (12% vs 13%; P = 0.93) recurrence rates.

CONCLUSIONS

In this analysis from a large international database, patients with muscle-invasive bladder cancer who received neoadjuvant chemotherapy before robot-assisted radical cystectomy had higher rates of survival, pathological downstaging, and margin-negative resections. They also experienced fewer distant recurrences.

Ileal conduit versus neobladder: A propensity score-matched analysis of the effect on renal function

OBJECTIVES

To analyze the long-term effects of continent (neobladder) compared with incontinent (ileal conduit) urinary diversion.

METHODS

We carried out a retrospective review of our departmental database. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Neobladder and ileal conduit patients were matched in a 1:2 ratio and a propensity score-matched analysis was carried out. Data were summarized using descriptive analysis. Trend plots were generated using baseline and follow-up creatinine values to compare estimated glomerular filtration rate at 3 months, then annually for 5 years. Variables associated with estimated glomerular filtration rate were assessed using multivariate linear analysis.

RESULTS

Our cohort consisted of 137 patients (neobladder n = 50 and ileal conduit n = 87) with a median follow-up time of 3 years (interquartile range 1-7 years). The ileal conduit group had shorter operative times (352 vs 444 min, P < 0.01), intracorporeal diversions were more common (66% vs 44%, P = 0.01), had prior abdominal surgery (66% vs 38%, P < 0.01) and had radiation (9% vs 0%, P = 0.03). The neobladder group more commonly had recurrent urinary tract infections (22% vs 3%, P < 0.01) and a steeper decrease in estimated glomerular filtration rate in the first year. On multivariate linear analysis, age/year (-0.59), body mass index per kg/m² (-0.52), preoperative estimated glomerular filtration rate per unit (0.51), recurrent urinary tract infections (-14.03) and time versus day 90 (year 1, -7.52; year 2, -9.06; year 3, -10.78) were significantly associated with estimated glomerular filtration rate.

CONCLUSION

Ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. Recurrent urinary tract infections were associated with a worse estimated glomerular filtration rate.

Cytotoxic Effects of Phytomediated Silver and Gold Nanoparticles Synthesised from Rooibos (Aspalathus linearis), and Aspalathin

The green chemistry approach has continuously been applied for the synthesis of functional nanomaterials to reduce waste, environmental hazards, and the use of toxic chemicals among other reasons. Bioactive natural compounds have been found great potential in this regard and are used to improve the stability, activity, and biodistribution of metal nanoparticles (MNPs). Aspalathin (ASP) from Aspalathus linearis (rooibos) has a well-defined pharmacological profile and functional groups capable of both reducing and capping agents in the synthesis of metallic nanoparticles (NP). This study provides the first report of the phytomediated synthesis of gold and silver nanoparticles (AuNPs/AgNPs) via ASP and the green rooibos (GR) extract. The study demonstrated a green chemistry approach to the biosynthesis of nanoparticles of GR-AuNPs, ASP-AuNPs, GR-AgNPs, and ASP-AgNPs. The results showed that GR and ASP could act both as reducing and stabilising agents in the formation of crystalline, with different shapes and dispersity of NPs in the ranges of 1.6-6.7 nm for AgNPs and 7.5-12.5 nm for the AuNPs. However, the ASP NPs were less stable in selected biogenic media compared to GR NPs and were later stabilised with polyethene glycol. The cytotoxicity studies showed that GR-AgNPs were the most cytotoxic against SH-SY5Y and HepG2 with IC₅₀ 108.8 and 183.4 μg/mL, respectively. The cellular uptake analysis showed a high uptake of AuNPs and indicated that AgNPs of rooibos at a lower dose (1.3-1.5 μg/mL) is favourable for its anticancer potential. This study is a contribution to plant-mediated metallic nanoparticles using a pure single compound that can be further developed for targeted drug delivery for cancer cells treatments in the coming years.

Intracorporeal Versus Extracorporeal Neobladder After Robot-assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

OBJECTIVE

To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-79606). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free, disease-specific, and overall survival.

RESULTS

Four hundred eleven patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (P <.01). Patients who received ICNB were readmitted and received neoadjuvant chemotherapy more frequently (36% vs 24%, P = .03, 35% vs 8%, P <.01, respectively). ICNB was associated with older age (OR 1.04, 95% CI 1.01-1.07, P = .001), receipt of neoadjuvant chemotherapy (OR 4.63, 95% CI 2.34-9.18, P <.01), and more recent RARC era (2016-2020) (OR 12.6, 95% CI 5.6-28.4, P <.01). On multivariate analysis, ICNB (OR 5.43, 95% CI 2.34-12.58, P <.01), positive surgical margin (OR 4.88, 95% CI 1.29-18.42, P = .019), longer operative times (OR 1.26, 95% CI 1.00-1.58, P = .048), and institutional annual RARC volume (OR 1.09, 95% CI 1.05-1.12, P <.01) were associated with readmissions.

CONCLUSION

Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

Material and geometric effects on propulsion of a fish tail

We investigate the effects of material flexibility and aspect ratio on the propulsion of flapping tails. The tail, which is assumed to deform in the bending direction only, is modeled using the Euler-Bernoulli beam theory. The hydrodynamic loads generated by the flapping motion are calculated using the three-dimensional unsteady vortex lattice method. The finite element method is used to solve the coupled time-dependent equations of motion using an implicit solver for time integration. The results show improvement in the thrust and propulsive efficiency over a specific range of non-dimensional flexibility defined by the ratio of the elastic forces to fluid pressure forces. Structural and flow characteristics associated with the improved performance are discussed. As for geometric effects, the performance depends on the excitation frequency. At low frequencies, the improvement is continuous with increasing the aspect ratio in a manner similar to that of rigid tails. At higher frequencies, the improvement is limited to a region defined by aspect ratios that are less than 0.5. The extent of the improvement depends on the flexibility.

Protective Effects of Linearthin and Other Chalcone Derivatives from Aspalathus linearis (Rooibos) against UVB Induced Oxidative Stress and Toxicity in Human Skin Cells

Skin cells suffer continuous damage from chronic exposure to ultraviolet light (UV) that may result in UV-induced oxidative stress and skin thinning. This has necessitated the formulation of cosmeceutical products rich in natural antioxidants and free radical scavengers. Aspalathus linearis (rooibos) is an endemic South African fynbos plant growing naturally in the Western Cape region. The plant is rich in phenolics and other bioactives with a wide spectrum of health benefits. The chemical study of an acetonic extract of green A. linearis afforded a novel compound named linearthin (1) and two known dihydrochalcones, aspalathin (2) and nothofagin (3). The chemical structure of the novel compound was elucidated based on spectroscopic data analysis. The bio-evaluation of the isolated chalcones in vitro for protection against UVB-induced oxidative stress were systematically assessed by examining cell viability, metabolic activity, apoptosis, and cytotoxicity using HaCaT and SK-MEL-1 skin cells models. It was observed that pre-treatment with tested samples for 4- and 24 h at low concentrations were sufficient to protect skin cells from UVB-induced damage in vitro as evidenced by higher cell viability and improved metabolic activity in both keratinocytes (HaCaT) and melanocytes (SK-MEL-1). The results further show that the pre-treatment regimen employed by this study involved some degree of cellular adaptation as evidenced by higher levels of reduced glutathione with a concomitant decrease in lipid peroxidation and lowered caspase 3 activity. Furthermore, compound 1 was most cytoprotective against UVB irradiation of HaCaT cell line (over 24 h) with an IC₅₀ of 282 µg/mL and SK-MEL-1 cell line with IC₅₀ values of 248.3 and 142.6 µg/mL over 4 and 24 h, respectively. On the other hand, HaCaT cells exposed to 2 over 4 h before UVB irradiation showed the highest degree of cytoprotection with an IC₅₀ of 398.9 µg/mL among the four studied samples. These results show that linearthin (1) and the two glycoside dihydrochalcone of A. linearis have the potential to be further developed as antioxidant cosmeceutical ingredients that may protect skin against UVB-induced damage.

Influence of hierarchy on risk communication during robot-assisted surgery: a preliminary study

INTRODUCTION

A hierarchical structure is where all individuals are organized according to importance and are subordinate to a single person. In the operating room (OR), this structure may negatively impact the quality of communication and jeopardize patient safety. We examined how the surgical team's hierarchical relationships affect the frequency and timing of risk communication, and their influence on situational awareness (SA) in the OR.

METHODS

Overhead cameras and lapel microphones were used to record the OR environment. Recordings and transcriptions of 10 robot-assisted prostatectomies were examined for risk utterances among team members. Utterances were classified by sender-recipient exchange, timing (determined by phrasing to be proactive or reactive to an error/negative event), and the Oxford Non-Technical Skills (NOTECHS) SA score. Surgeon's and trainee surgeon's utterances were classified by their on-console status. Chi-square tests were used to determine associations between dependent factors, and ANOVAs were used to evaluate the effect of hierarchy and timing on NOTECHS score.

RESULTS

Of 4,583 examined utterances, 329 (7%) were risk-related. There was no significant difference in utterance frequency based on hierarchical status of sender and recipient (p = 0.16). Utterances made by the surgeon or trainee surgeon had higher NOTECHS scores when off versus on the console (scores: 1.8 vs 2.4, p < 0.01). These utterances were more reactive on the console (32%) and proactive off the console (28%). Proactive utterances had higher NOTECHS scores than reactive utterances (scores: 2.5 vs 1.8, p < 0.01).

CONCLUSION

The surgical hierarchy significantly impacted the frequency of risk communication within the OR. Timing and on-console status further influenced the efficacy of risk communication.

Utilizing deep neural networks and electroencephalogram for objective evaluation of surgeon's distraction during robot-assisted surgery

OBJECTIVE

To develop an algorithm for objective evaluation of distraction of surgeons during robot-assisted surgery (RAS).

MATERIALS AND METHODS

Electroencephalogram (EEG) of 22 medical students was recorded while performing five key tasks on the robotic surgical simulator: Instrument Control, Ball Placement, Spatial Control II, Fourth Arm Tissue Retraction, and Hands-on Surgical Training Tasks. All students completed the Surgery Task Load Index (SURG-TLX), which includes one domain for subjective assessment of distraction (scale: 1-20). Scores were divided into low (score 1-6, subjective label: 1), intermediate (score 7-12, subjective label: 2), and high distraction (score 13-20, subjective label: 3). These cut-off values were arbitrarily considered based on a verbal assessment of participants and experienced surgeons. A Deep Convolutional Neural Network (CNN) algorithm was trained utilizing EEG recordings from the medical students and used to classify their distraction levels. The accuracy of our method was determined by comparing the subjective distraction scores on SURG-TLX and the results from the proposed classification algorithm. Also, Pearson correlation was utilized to assess the relationship between performance scores (generated by the simulator) and distraction (Subjective assessment scores).

RESULTS

The proposed end-to-end model classified distraction into low, intermediate, and high with 94%, 89%, and 95% accuracy, respectively. We found a significant negative correlation (r = -0.21; p = 0.003) between performance and SURG-TLX distraction scores.

CONCLUSIONS

Herein we report, to our knowledge, the first objective method to assess and quantify distraction while performing robotic surgical tasks on the robotic simulator, which may improve patient safety. Validation in the clinical setting is required.

"Put the what, where? Cut here?!" challenges to coordinating attention in robot-assisted surgery: a microanalytic pilot study

INTRODUCTION

During robot-assisted surgery (RAS), changes to the operating room configuration pose challenges to communication by limiting team members' ability to see one another or use gesture. Referencing (the act of pointing out an object or area in order to coordinate action around it), may be susceptible to miscommunication due to these constraints.

OBJECTIVES

Explore the use of microanalysis to describe and evaluate communicative efficiency in RAS through examination of referencing in surgical tasks.

METHODS

All communications during ten robot-assisted pelvic surgeries (radical cystectomies and prostatectomies) were fully transcribed. Forty-six referencing events were identified within these and subjected to a process of microanalysis. Microanalysis employs detailed transcription of speech and gesture along with their relative timing/sequencing to describe and analyse interactions. A descriptive taxonomy for referencing strategies was developed with categories including references reliant exclusively on speech (anatomic terms/directional language and context dependent words (CD)); references reliant exclusively on gesture or available aspects of the environment (point/show, camera focus/movement in the visual field and functional movement); and references reliant on the integrated use of speech and gesture/environmental support (integrated communication (IC)). Frequency of utilisation and number/percent 'miscommunication', were collated within each category when miscommunication was defined as any reference met with incorrect or no identification of the target.

RESULTS

IC and CD were the most frequently used strategies (45% and 26%, respectively, p≤0.01). Miscommunication was encountered in 22% of references. The use of IC resulted in the fewest miscommunications, while CD was associated with the most miscommunications (42%). Microanalysis provided insight into the causes and nature of successful referencing and miscommunication.

CONCLUSIONS

In RAS, surgeons complete referencing tasks in a variety of ways. IC may provide an effective means of referencing, while other strategies may not be adequately supported by the environment.

Neuroprotective Activities of Crossyne flava Bulbs and Amaryllidaceae Alkaloids: Implications for Parkinson's Disease

Parkinson’s disease (PD) is one of the most common neurodegenerative diseases and affects approximately 6.3 million people worldwide. To date, the treatment of PD remains a challenge, as available treatment options are known to be associated with serious side effects; hence, the search for new treatment strategies is critical. Extracts from the Amaryllidaceae plant family as well as their alkaloids have been reported to have neuroprotective potentials. This study, therefore, investigated the biological activities of Crossyne flava and its isolated alkaloids in an in vitro MPP⁺ (1-methyl-4-phenylpyridinium) PD model using SH-SY5Y cells. The effects of the total extract as well as the four compounds isolated from Crossyne flava (i.e., pancratinine B (1), bufanidrine (2), buphanisine (3), and epibuphanisine (4)) were evaluated for cell viability, neuroprotection, levels of reactive oxygen species (ROS), adenosine triphosphate activity (ATP), and caspase 3/7 activity in SH-SY5Y cells. The results obtained showed that pre-treatment with both the extract and the isolated compounds was effective in protecting the SH-SY5Y cells from MPP⁺-induced neurotoxicity and inhibited ROS generation, ATP depletion as well as apoptosis induction in the SH-SY5Y cells. The results of this study show that the Amaryllidaceae plant family may be a source of novel compounds for the treatment of neurodegenerative diseases, which validates the reported traditional uses.

Ex vivo human testes as a practical model to simulate ultrasound-guided testicular cell transplantation for human fertility restoration

OBJECTIVE

To develop an ex vivo model to practice ultrasound-guided injection of cellular material into human seminiferous tubules to simulate testicular cell transplantation (TCT).

DESIGN

Simulated TCT injections were performed in human testes removed during orchiectomy. The rete testis was the target site of injection. Successful retrograde infiltration of injected material into the lumen of the seminiferous tubules was detected using ultrasound and confirmed with histology.

SETTING

Single academic surgical center.

PATIENT(S)

Adult patients undergoing orchiectomy for nononcologic indications.

INTERVENTION(S)

The testes were injected with sonographic contrast (Optison), methylene blue, and fluorescent-labeled cells.

MAIN OUTCOME MEASURE(S)

A characteristic streaming pattern of sonographic contrast in the testis was used to define sonographic success, and the presence of methylene blue and fluorescent-labeled cells within the seminiferous tubules confirmed histologic success.

RESULT(S)

We performed simulated TCT injections in 30 testes obtained from 16 patients undergoing orchiectomy. We were able to achieve sonographic success in 57% of injections and confirmed that sonographic success is correlated with histologic success.

CONCLUSION(S)

Testicular cell transplantation injections can be practiced using human testes. As there appears to be a learning curve associated with this procedure, developing this infrastructure to practice these skills is critical before implementation in patients.

Functional outcomes after robot-assisted radical cystectomy: A review of literature

Robot-assisted radical cystectomy has steadily gained wider acceptance among urologists compared with open and laparoscopic approaches. Robot-assisted radical cystectomy has shown comparable perioperative and oncologic outcomes compared with open radical cystectomy. Nevertheless, data about the functional outcomes and quality of life after robot-assisted radical cystectomy remain limited. We sought to review the literature and describe urinary, sexual and bowel functions after robot-assisted radical cystectomy in addition to mental health and health-related quality of life. Despite limitations of the available literature, data suggests that functional outcomes after robot-assisted radical cystectomy are comparable to open radical cystectomy. However, more studies utilizing standardized definitions are required.

Surgical Hand Gesture Recognition Utilizing Electroencephalogram as Input to the Machine Learning and Network Neuroscience Algorithms

Surgical gestures detection can provide targeted, automated surgical skill assessment and feedback during surgical training for robot-assisted surgery (RAS). Several sources including surgical videos, robot tool kinematics, and an electromyogram (EMG) have been proposed to reach this goal. We aimed to extract features from electroencephalogram (EEG) data and use them in machine learning algorithms to classify robot-assisted surgical gestures. EEG was collected from five RAS surgeons with varying experience while performing 34 robot-assisted radical prostatectomies over the course of three years. Eight dominant hand and six non-dominant hand gesture types were extracted and synchronized with associated EEG data. Network neuroscience algorithms were utilized to extract functional brain network and power spectral density features. Sixty extracted features were used as input to machine learning algorithms to classify gesture types. The analysis of variance (ANOVA) F-value statistical method was used for feature selection and 10-fold cross-validation was used to validate the proposed method. The proposed feature set used in the extra trees (ET) algorithm classified eight gesture types performed by the dominant hand of five RAS surgeons with an accuracy of 90%, precision: 90%, sensitivity: 88%, and also classified six gesture types performed by the non-dominant hand with an accuracy of 93%, precision: 94%, sensitivity: 94%.

Potential Application of Some Lamiaceae Species in the Management of Diabetes

Diabetes is one of the most dangerous metabolic disorders, with high rates of mortality worldwide. Since ancient times, medicinal plants have been used in traditional medicine to treat many diseases, including diabetes and its related complications. Plants are widely accepted, affordable, and perceived to have minimal adverse side effects. The Lamiaceae family is a potential source of therapeutic agents for the management of metabolic disorders, including diabetes. Hence, this review paper summarizes the antidiabetic use of Lamiaceae species in folk medicine globally. Furthermore, we present the antidiabetic activities and phytochemical constituents of twenty-three (23) Lamiaceae species and the antidiabetic activity of some notable chemical constituents isolated from some of these Lamiaceae species.

Abietane Diterpenes as Potential Candidates for the Management of Type 2 Diabetes

Diabetes mellitus (DM) is considered one of the most common metabolic disorders with an elevated morbidity and mortality rate. It is characterised by a deficiency in insulin secretion or degradation of secreted insulin. Many internal and external factors, such as oxidative stress, obesity and sedentary lifestyle, among others, have been suggested as the major causes of these cell alterations. Diabetes I and II are the most common types of diabetes. Treatment of type I requires insulin injection, while type II can be managed using different synthetic antidiabetic agents. However, their effectiveness is limited as a result of low bioavailability, high cost of drug production, and unfavourable side effects. There is a great need to develop alternative and more active antidiabetic drugs from natural sources. Different forms of natural products have been used since time immemorial as a source of medicine for the purpose of curing numerous human diseases, including diabetes. Secondary metabolites such as polyphenols, flavonoids, terpenoids, alkaloids and several other constituents have direct and indirect roles in controlling such diseases; among them, abietane diterpenes have been reported to display a broad spectrum of promising biological activities including diabetes. This review aimed to summarize existing data from SciFinder (2005-2018) on the biological importance of abietane diterpenes in the prevention and management of type 2 diabetes and closely related diseases.

Validation of the Khorana Score for Prediction of Venous Thromboembolism After Robot-Assisted Radical Cystectomy

Introduction: The Khorana score (KS) is used to predict the risk of venous thromboembolism (VTE) for cancer patients. We sought to assess the association between KS and VTE for patients who underwent robot-assisted radical cystectomy (RARC). Materials and Methods: We reviewed our prospectively maintained quality assurance RARC database between 2005 and 2020. KS was calculated for all patients (one point for each body mass index [BMI] ≥35 kg/m², platelet count ≥350 × 10⁹/L, leukocyte count >11 × 10⁹/L, and hemoglobin level <10 g/dL, or use of erythropoiesis-stimulating agents). All patients received one point by default for the cancer type (bladder). Patients were divided into intermediate-risk (KS 1-2) or high-risk (KS ≥3) groups. Receiver operating characteristic curve was used to assess the ability of KS to predict VTE. Kaplan-Meier curves were stratified based on their KS risk and used to depict overall survival (OS). Multivariate analysis (MVA) was used to identify variables associated with VTE. Results: Out of 589 patients, 33 (6%) developed VTE (18 had deep vein thrombosis and 15 had pulmonary embolism). Five hundred forty-six (93%) patients had intermediate-risk KS and 30 (5%) of them developed VTE. Forty-three (7%) patients were classified as high-risk KS and 3 (7%) developed VTE. This difference was not significant (p = 0.73). The KS area under the curve for VTE prediction was 0.51. On MVA, BMI ≥35 kg/m² (odds ratio [OR] 2.69, confidence interval [CI] 1.19-6.11, p = 0.02), longer inpatient stay (OR 1.04, CI 1.003-1.07, p = 0.03), and ≥pT₃ disease (OR 2.29, CI 1.11-4.71, p = 0.03) were associated with VTE, whereas KS was not associated with VTE (p = 0.68). Five-year OS of patients with intermediate KS was 53% compared with 30% for high-risk KS (log rank p < 0.01). Conclusion: KS underestimated VTE risk after RARC and showed poor accuracy. This highlights the need to develop procedure-specific tools to estimate the risk of VTE after RARC.