Abbreviations & Acronyms Cr = creatinine CT = computed tomography eGFR = estimated glomerular filtration rate MDCT = Multidetector computed tomography PADUA = Preoperative Aspects and Dimensions Used for an Anatomical PN = partial nephrectomy RAPN = robot-assisted partial nephrectomy RCV = renal cortical volume RENAL = Radius, Exophytic/endophytic properties, Nearness of the tumor to the collecting system or sinus, Anterior/posterior, Location relative to the polar lines RPV = renal parenchymal volume RV = resection volume VPNA = virtual partial nephrectomy analysis Objectives: To evaluate the feasibility and accuracy of virtual partial nephrectomy analysis, including a color-coded three-dimensional virtual surgical planning and a quantitative functional analysis, in predicting the surgical outcomes of robot-assisted partial nephrectomy. Methods: Between 2012 and 2014, 20 patients underwent virtual partial nephrectomy analysis before undergoing robot-assisted partial nephrectomy. Virtual partial nephrectomy analysis was carried out with the following steps: (i) evaluation of the arterial branch for selective clamping by showing the vascular-supplied area; (ii) simulation of the optimal surgical margin in precise segmented three-dimensional model for prediction of collecting system opening; and (iii) detailed volumetric analyses and estimates of postoperative renal function based on volumetric change. At operation, the surgeon identified the targeted artery and determined the surgical margin according to the virtual partial nephrectomy analysis. The surgical outcomes between the virtual partial nephrectomy analysis and the actual robotassisted partial nephrectomy were compared. Results: All 20 patients had negative cancer surgical margins and no urological complications. The tumor-specific renal arterial supply areas were shown in color-coded threedimensional model visualization in all cases. The prediction value of collecting system opening was 85.7% for sensitivity and 100% for specificity. The predicted renal resection volume was significantly correlated with actual resected specimen volume (r 2 = 0.745, P < 0.001). The predicted estimated glomerular filtration rate was significantly correlated with actual postoperative estimated glomerular filtration rate (r 2 = 0.736, P < 0.001). Conclusions: Virtual partial nephrectomy analysis is able to provide the identification of tumor-specific renal arterial supply, prediction of collecting system opening and prediction of postoperative renal function. This technique might allow urologists to compare various arterial clamping methods and resection margins with surgical outcomes in a non-invasive manner.Key words: robot-assisted partial nephrectomy, simulation, three-dimensional anatomical model, virtual operation, volumetry. IntroductionCurrently, the treatment for stage I renal tumors is nephron-sparing surgery, which is the standard of care for T1a and most T1b tumors, and the role of RAPN in the nephron-sparing surgery armamentarium is expanding. [1][2][3][4] In 20...

increased intraindividual variability in several biological parameters is associated with aspects of frailty and may reflect impaired physiological regulation. As frailty involves a cumulative decline in multiple physiological systems, we aimed to estimate the overall regulatory capacity by applying a principal component analysis to such variability. The variability of 20 blood-based parameters was evaluated as the log-transformed coefficient of variation (LCV) for one year's worth of data from 580 hemodialysis patients. All the LCVs were positively correlated with each other and shared common characteristics. In a principal component analysis of 19 LCVs, the first principal component (PC1) explained 27.7% of the total variance, and the PC1 score exhibited consistent correlations with diverse negative health indicators, including diabetes, hypoalbuminemia, hyponatremia, and relative hypocreatininemia. the relationship between the PC1 score and frailty was subsequently examined in a subset of the subjects. The PC1 score was associated with the prevalence of frailty and was an independent predictor for frailty (odds ratio per SD: 2.31, P = 0.01) using a multivariate logistic regression model, which showed good discrimination (c-statistic: 0.85). Therefore, the PC1 score represents principal information shared by biomarker variabilities and is a reasonable measure of homeostatic dysregulation and frailty. Studies on variability in blood pressure, plasma glucose levels, hemoglobin concentration, and other parameters have commonly reported associations with adverse outcomes 1-3. In our previous study examining patients receiving maintenance hemodialysis (HD), variability in many other blood-based laboratory parameters was also related to several adverse conditions, such as impaired mobility, hospital admission, increased mortality, and hypoalbuminemia 4. These conditions are in fact elements of frailty, and frailty is considered to be a state of functional decline in many physiological systems 5. Therefore, we speculated that the variability in laboratory parameters may reflect the dysfunction of corresponding regulatory systems and may also be a measure of frailty. Consistent with this idea, the variability of serum albumin concentrations increases with ageing, and this movement accelerates prior to death 6. Others have also suggested a link between physiological regulation and variability in other biological variables 7-10. However, the variability of a single parameter may not properly represent the dysregulation across multiple physiological systems in frailty 11. To develop a comprehensive measure of physiological dysregulation that is consistent with the concept of frailty, we applied a principal component analysis (PCA) to a set of variabilities in laboratory parameters. This procedure, performed on all study participants (n = 580), yielded principal component scores (PC scores) for

To our knowledge, this is the first study to show that combination therapy of L-citrulline and transresveratrol is effective for ED treatment in men with added on-demand use of PDE5i. This combination supplement may be added if PDE5i is insufficient. Shirai M, Hiramatsu I, Aoki Y, et al. Oral L-citrulline and Transresveratrol Supplementation Improves Erectile Function in Men With Phosphodiesterase 5 Inhibitors: A Randomized, Double-Blind, Placebo-Controlled Crossover Pilot Study. Sex Med 2018;6:291-296.

Combining MDCT renal volumetry and clinical indices might yield an important tool for predicting postoperative renal function.

Hemoglobin (Hb) is associated with cerebral oxygenation status owing to its important role of carrying oxygen to systemic tissues. However, data concerning the associations between Hb levels and cerebral regional oxygen saturation (rSO 2) of hemodialysis (HD) patients is limited. We aimed to identify these associations to consider a target Hb level for renal anemia management. This study included 375 HD patients. Cerebral rSO 2 before HD was monitored using the INVOS 5100c oxygen saturation monitor. Multivariable linear regression analysis showed that cerebral rSO 2 was independently associated with natural logarithm (Ln)-HD duration (standardized coefficient:-0.36), mean blood pressure (standardized coefficient: 0.13), pH (standardized coefficient:-0.10), serum albumin (standardized coefficient: 0.14), presence of diabetes mellitus (standardized coefficient:-0.20), and Hb level (standardized coefficient: 0.29). Furthermore, a generalized linear model with restricted cubic spline function was used to investigate the non-linear association between cerebral rSO 2 and Hb levels. In the multivariable analysis for the adjustment with Ln-HD duration, mean blood pressure, pH, serum albumin, and presence of diabetes mellitus, a linear relationship was demonstrated between the two variables (p for linearity = 0.79). Hb levels revealed the positive and significant association with cerebral rSO 2 in this study. Moreover, the relationship between cerebral rSO 2 and Hb level was proven to be linear. Therefore, the target Hb level in renal anemia management would be considered to be the upper limits for the appropriate management of renal anemia by previous guidelines and position statement from the viewpoint of maintaining cerebral oxygenation in HD patients.