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1 UROLOGY ROBOTIC SURGERY Arch. Esp. Urol., 60, 4 ( ), 2007 VATTIKUTI INSTITUTE PROSTATECTOMY (VIP) AND CURRENT RESULTS. Mahendra Bhandari and Mani Menon. Vattikuti Urology Institute. Henry Ford Health System. Detroit. USA. Summary.- OBJECTIVES: To describe a technique of Robot Assisted Radical Prostatectomy (RAP) for localized carcinoma of the prostate, the Vattikuti Institute Prostatectomy (VIP) and an innovative incremental nerve preservation technique, the Veil of Aphrodite. We also report complications, oncolgical and functional outcomes in a cohort of the patient operated during METHODS: patients with localiced carcinoma of prostate underwent VIP at our centre between Our current technique involves: early division of the bladder neck, preservation of the lateral pelvic fascia and control of the dorsal vein complex after apical dissection of the prostate. Oncological, functional and follow-up information was obtained through ROBO- SURG data base, which is managed by an independent group not involved in the patient care. VIP, as it has evolved in our hands over a period of 5 years, has given excellent outcomes in terms of cancer control, continence and erectile function. Our modifications of the surgical technique had a singular focus on consistent improvement of the so called Trifecta, taking radical retropubic prostatectomy (RRP) published data as a reference standard. We present our current technique of VIP with preservation of the lateral prostatic fascia ( Veil of Aphrodite ). RESULTS: In this report we include 2077 patients with follow-up ranging from 4 weeks to 260 weeks (median 68 weeks). We have a low incidence (1.5%) of perioperative complications. 97.6% of our patients had a hospital stay of less than 48 hours. There were 5.8% unscheduled postoperative visits. With the PSA cut-off limit of 0.4ng/ml, the overall biochemical recurrence rate was 3.9%. Median duration of incontinence was 4 weeks; 0.8% patients had total incontinence at 12 months. The intercourse rate was 93% in men with no pre-operative erectile dysfunction undergoing veil nervesparing surgery, although only 51% returned to baseline function. Correspondence Mahendra Bhandari M.D. Vattikuti Urology Institute Henry Ford Health System 2799 West Grand Blvd. Detroit, MI, 48202, USA. CONCLUSION: Vattikuti Institute Prostatectomy offers excellent patient recovery with significant reduction in first 30 days morbidity and provides excellent oncological and functional outcomes. The preservation of the Veil of Aphrodite helps in postoperative return of erectile function in patients with normal preoperative erectile function. Keywords: Robotic. Radical prostatectomy. Prostate cancer. Laparoscopy.
2 398 M. Bhandari and M. Menon. INTRODUCTION METHODS Radical prostatectomy for localized carcinoma of the prostate reduces disease-specific and overall mortalities as well as the risk of metastases and local progression (1). Over past several decades RRP has consolidated as a refined surgical procedure, with excellent outcomes (2-4). Recent trends favor minimally invasive surgical techniques for removing the prostate (5,6). Our technique, the Vattikuti Institute Prostatectomy (VIP), was implemented to the routine surgical care of patients with localized prostate cancer in 2001 (7,8) and has been widely adopted by others (9-11). In 2003 we introduced a major modification of the preservation of lateral pelvic fascia - the Veil of Aphrodite which has improved postoperative erectile function significantly (12,13). From we have performed 2652 RRPs. In this report, we describe our current technique; early oncological and functional results in 2077 patients. DEVELOPMENT OF V.I.P The post PSA era has significantly contributed to the early diagnosis of prostate cancer as well as increased its cure rates. Erectile dysfunction is the most distressing adverse outcome that the patients sustain following open radical prostatectomy (14). Our technique harnesses the precision inherent in robotic surgery for better nerve preservation and resultant improved potency, without compromising cancer control. Over a period of 5 years, we made the following modifications in our technique and found certain maneuvers helpful in achieving our objectives including division of the bladder neck initially (first done in 2001), application of a running suture for urethrovesical anastomosis (2001), and incising the prostatic fascia anterolaterally to release the nerves (2003). These techniques have resulted in a decrease in operative times, incidence of anastomotic leaks and of erectile dysfunction, respectively. In 2004 (after more than 1000 cases) we changed our technique of traction on the bladder neck and abandoned initial bulk ligation of the dorsal vein complex, in favor of precise suturing after urethral transection. Starting in 2002, we eliminated the use of monopolar cauterization after the division of the seminal vesicle. In 2004 we stopped opening endopelvic fascia, and started preserving the anterior fibromuscular stroma of the prostate in select patients with low volume disease. PATIENT SELECTION While respecting patient preferences for surgery, we generally recommend that men with low PSA and focal Gleason 6 cancer of the prostate undergo active monitoring with follow-up biopsies. We offer surgery for men with non-focal Gleason 6 cancer (35.6% of our patients), Gleason 7 (54.7%) and Gleason 8-10 cancer (9.7 %). Patients with >25% Gleason 7 disease get conventional nerve sparing (2,3) on the ipsilateral side: all others get the veil nerve sparing (12). TECHNIQUE OF VIP (15) Patient positioning and port placement The patient is padded at pressure points and placed in dorsal lithotomy position. Pneumoperitoneum is created using a Veress needle and ports are placed under vision. We use a six port approach. (Figure 1) The table is then moved to steep (30 degree) Trendelenburg position. Robotic Instruments The operation can be done with either the 8 mm or 5 mm robotic instruments. We currently prefer the latter. We use a combination of the monopolar hook, the cold round tip scissors, a Maryland or triangular (Precise) bipolar grasper and needle holders. In patients in whom nerve-sparing is not contemplated, the scissors can be eliminated and the procedure can be done with 3 instruments, thus reducing the cost. FIGURE 1. Port Placement.
3 VATTIKUTI INSTITUTE PROSTATECTOMY (VIP) AND CURRENT RESULTS. 399 FIGURE 2. Transperitoneal access to the extraperitoneal space. The extraperitoneal space is entered through an inverted, U-shaped incision on the parietal peritoneum, superior to the dome of the bladder and lateral to the medial umbilical ligaments. The vertical limb of the peritoneal incision is made lateral to the medial umbilical ligament, and medial to the internal inguinal ring. The incisions are joined anteriorly, dividing the bilateral medial umbilical ligaments (yellow- arrow heads) and urachus, and then the bladder is dissected off the anterior abdominal wall to enter into the space of Retzius Development of the extraperitoneal space The peritoneal cavity is inspected using the 30-degree upward-looking lens. A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament; this incision is extended in an inverted U to the level of the vasa on either side. The space anterior to the peritoneum and space of Retzius is thus entered. The rest of the surgery is performed in this space anterior to the peritoneal reflection of the bladder and prostate (Figure 2). Lymph node dissection The tissue overlying the external iliac vein is incised and lymph nodal package is pushed medially. The dissection is started at the lymph node of Cloquet in the femoral canal and continued proximally toward the bifurcation of iliac vessels. The obturator nerve lies on the floor of this dissection and is carefully preserved (Figure 3). In patients with Gleason 8-10 disease, the nodal package between the obturator nerve and the hypogastric vein is also removed. Bladder Neck Transection We next approach the bladder neck directly, without opening endopelvic fascia or ligating the dorsal vein complex, a modification over our previously FIGURE 3. Pelvic lymphadenectomy. The packet is cleared from the anterior and medial surface of the external iliac vein (blue- arrow head). Obturator nerve (yellow- arrow head) is identified and serves as the posterior margin of dissection. The packet of fibro-fatty and nodal tissue (red- arrow head) is dissected toward the bifurcation of the external iliac vein. described technique (8). This portion of the procedure is best done with a 30-degree lens looking down. The right assistant grasps the anterior bladder wall in the mid line with an atraumatic grasper, lifts it directly towards the anterior abdominal wall and the left assistant deflates the Foley balloon while keeping the catheter in the bladder. This simple maneuver aids in the identification of the bladder neck as the bladder pulls away from the prostate excepting at the midline anterior to the catheter (Figure 4). A 1 cm incision is made in the anterior bladder neck at 12 O clock, cutting down the detrusor to expose the catheter in the mid-line (Figure 5). A detrusor apron may be seen on the anterior surface of the prostate (17). The incision in the bladder neck is made immediately superior to the detrusor apron. After the anterior bladder neck is incised, the Foley catheter is delivered and the left-side assistant grasps the tip of the Foley catheter with firm anterior traction. This exposes the posterior bladder neck, which is then incised (Figure 6). The posterior bladder neck is gradually dissected away from the prostate. The anterior layer of Denonvillier s fascia is now exposed. (Figure 7) and is incised precisely, exposing the vasa and the seminal vesicles. The left-side assistant provides upward traction to the posterior base of the prostate to facilitate dissection of the vasa and seminal vesicles.
4 400 M. Bhandari and M. Menon. FIGURE 4. Bladder neck identification. FIGURE 5. Division of anterior bladder neck. The right assistant grasps the anterior bladder wall in the mid line with an atraumatic grasper, lifts it directly towards the ceiling and the left assistant deflates the Foley balloon while keeping the catheter in the bladder. The bladder pulls away from the prostate excepting at the midline anterior to the catheter. (Black- arrow heads) A one cm incision is made in the anterior bladder neck at 12 O clock, cutting down the detrussor to the expose the catheter in the midline (Yellow-arrow head). If correct plane is entered there is minimal bleeding from the incision (Blue-arrow head). First the vasa are skeletonized and transected, then held upward by the left assistant providing further traction for dissection of the seminal vesicles. The artery to the seminal vesicle is controlled by clipping or fine bipolar coagulation. Both the vasa and seminal vesicles are then grasped and the posterior prostate is retracted upwards, allowing exposure of posterior layer of the Denonvilliers fascia. An incision is made in this fascia and a plane is developed between the posterior layer of the Denonvillier s fascia and perirectal fat. This hypo-vascular plane can be created easily using blunt dissection. The dissection is carried down to the apex of the prostate. This plane of dissection is extended laterally to expose the lateral pedicles of the prostate. The base of the seminal vesicle is retracted superomedially by the assistant on the opposite side and the prostatic pedicle is delineated and divided. This pedicle lies anterior to the pelvic plexus and neurovascular bundle and includes only prostatic blood supply. The pedicles are controlled by either clipping or individually coagulating the vessels by bipolar cauterization. Nerve sparing techniques: the Veil of Aphrodite Although the classical description of the neurovascular bundles is that of two bundles of tissue that are located near the posterolateral surface of the prostate (2) there is accumulating evidence that there is variability in this complex. In some patients, rather than distinct neurovascular bundles, the cavernosal nerves form lattices or curtains that extend from the postero-lateral to the antero-lateral surface of the prostate (17-20). In order to preserve these nerves, several surgeons (4,22) and we (12) have modified FIGURE 6. Dissection of the posterior bladder neck. After the anterior bladder neck is incised, the left-side assistant grasps the tip of the Foley catheter with firm anterior traction. (Blue-arrow head). This pulls up the posterior bladder neck (Yellow-arrow head)., which is then incised.
5 VATTIKUTI INSTITUTE PROSTATECTOMY (VIP) AND CURRENT RESULTS. 401 nerve-sparing techniques by dissecting the prostatic fascia off the prostate postero-laterally and incising it anteriorly. We termed this approach, the veil of Aphrodite nerve-sparing technique (Aphrodite is the Greek goddess of love who causes strong men to fight over her); latterly, others have called it high anterior release, curtain dissection, or incremental nerve sparing. In the Veil procedure we accomplish this through an antegrade approach. A plane between the prostatic capsule and the prostatic fascia is developed cranially, at the base of the seminal vesicles (Figure 8). With appropriate counter-traction provided by the assistants the surgeon is able to enter a plane between the prostatic fascia and the prostate. This plane is deep to the venous sinuses of Santorini s plexus. Careful sharp and blunt dissection of the neurovascular bundle and contiguous prostatic fascia is performed using the articulated cold scissors until the entire prostatic fascia up to the pubourethral ligament is mobilized in continuity. This plane is mostly avascular, except anteriorly where the fascia is fused with the pubo-prostatic ligament, and covers the dorsal venous plexus. When performed properly, curtains of periprostatic tissue hang from the pubourethral ligament, the veil of Aphrodite (Figure 9). If this plane is difficult to enter (patients with post-biopsy fibrosis), we perform part of the dissection retrograde, and enter the plane on the anterolateral surface of the prostatic capsule at the 10- or 2- o clock position. Exposure of prostatic apex and control of dorsal venous complex The prostatic apex is best visualized using the 0 degree lens; this is particularly useful in patients with an overhanging pubic symphysis. Once the lateral prostatic fascia is dissected off the prostatic apex, the right assistant retracts the prostate firmly to the patient s head. The puboprostatic ligament is incised with the cold scissors where it inserts into the apical prostatic notch (Figure 10). It is important not to skeletonize the urethra as maintaining the fibrovascular support of the urethra intact hastens the return of continence. The cavernosal nerves are close to the urethra and are vulnerable to thermal or traction injury. The urethra is then dissected into the prostatic notch and transected sharply 5mm distal to the notch. The freed specimen is then placed in an Endopouch TM (Ethicon Endo-Surgery Inc.). FIGURE 7. Incision of the Denonvillier s fascia. After the division of full thickness of detrussor at posterior bladder neck the left-side assistant provides upward traction to the posterior base of the prostate (Blue-arrow head).the right assistant retracts the bladder posterior (Yellow-arrow head). This exposes the anterior layer of Denonvillier s fascia covering both vasa deferentia and seminal vesicles (Red-arrow head). This fascia in incised to create a window from where the vasa deferentia and seminal vesicles can be pulled anteriorly and dissected. FIGURE 8. Dissection of the plane for Veil of Aphrodite. After the prostatic pedicle are controlled. A plane between the prostatic capsule (Black-arrow head) and the periprostatic fascia layer (Yellow-arrow head) is developed at the cranial extent of the prostate. Dissection in this plane is continued anteriorly and caudally separating the peri-prostatic fascia from the prostate on its anterolateral aspect.
6 402 M. Bhandari and M. Menon. The dorsal venous complex is controlled with an overrunning suture of 2-0 braided polyglactin on 17 mm tapercut needle. (Figure 11). Depending on the amount of oozing from the dorsal vein complex, control is done before or after urethral transection Urethrovesical Anastomosis A running suture is used for the urethrovesical anastomosis. We use a minor modification of the technique described by Van Velthoven (22). One dyed and one undyed seven-inch 3-0 monofilament polyglecaprone-25 sutures on 17 mm tapercut needles are tied back to back. The suture is now double-armed with a pledget of the knots in the middle. We start with dyed arm, on the posterior bladder wall at 4 o clock position outside-in, continuing into the urethra at the corresponding site, inside-out. The dyed arm is run for two bites in the urethra and three in the bladder neck; the bladder is then cinched down to the urethra, with the right assistant following the suture. After the posterior urethral wall is approximated to the bladder neck in its entirety, the direction of the stitch is then changed to get passage of the needle from outside-in bladder to inside out. The suture is run clockwise up to 11 o clock position, and handed to the left assistant to hold with gentle, approximating traction. The undyed arm is then run counter clockwise from 4 o clock to 11 o clock. During the placement of anastomotic sutures the left assistant moves the tip of urethral Foley in an out of the urethral stump to prevent suturing of the back wall of urethra. Both arms of the suture are tied to each other to complete the anastomosis. A new 20 French Foley catheter is introduced and its balloon is inflated to 20 cc. The bladder is filled with 250 cc saline to test the integrity of the anastomosis. Retrieval of specimen and completion of surgery A Jackson-Pratt drain is placed through left 5 mm port. The specimen is removed after enlarging the umbilical port incision as required. The incision is closed with interrupted sutures of 0 braided polyester. The skin is closed with self-absorbing subcuticular sutures. Postoperative care In order to minimize the urine spillage in to the operating field, intravenous fluids are restricted to a minimum during the surgery. All patients receive a 1000 ml bolus of intravenous fluid in recovery room. Once on the floor they start on clear liquid diet and advance to regular diet after a bowel movement. All patients are encouraged to ambulate within four hours of arrival on floor. The Jackson-Pratt drain is removed on day one and patients are discharged within 24 hours with an indwelling Foley catheter. The catheter is removed on day 7 or after under cystographic control. FIGURE 9. Veil of Aphrodite. Preserved veil of Aphrodite after the prostate is extirpated. After removal of the prostate from the prostatic fossa, peri-prostatic fascia (White-arrow heads) hangs from the bladder (Yellow-arrow head) to the urethra on either side. FIGURE 10. Apical dissection. The puboprostatic ligaments and the dorsal venous complex (blue-arrow head) are divided to expose urethra. The urethra is then dissected into the prostatic notch (Redarrow head). The urethra is transected sharply 3-5mm distal to the notch. The anterior wall is cut with the Foley catheter across the urethra (Yellow-arrow head).
7 VATTIKUTI INSTITUTE PROSTATECTOMY (VIP) AND CURRENT RESULTS. 403 Data collection and analysis Preoperative demographic and operative data were collected prospectively in a customized database ROBOSURG. Pathological specimens were examined by one of several individual pathologists, with randomly selected specimens being reviewed by a referee pathologist. Patients were surveyed with a mailed-in questionnaire that included IPSS and SHIM scoring sheets, and questions about pad usage and duration of incontinence. Non-respondents were followed-up persistently by the database manager through a series of periodic communications including phone call reminders. The data were analyzed with an SPSSTM (SPSS Corporation, Chicago, IL) statistical software package. increasing house staff participation and surgical complexity (greater utilization of veil nerve sparing). The positive margin rate at the apex was 12% for the first 100 cases (23). When initial bulk ligation of the dorsal vein complex was replaced with suture ligation of RESULTS Preoperative and operative parameters From March 2001 to September 2006, we have operated on 2652 patients, 2582 at our own institution. Pre operative and operative parameters are detailed in Figure 12. In keeping with our philosophy, patients in this series had higher Gleason grade disease (64.4% > than Gleason 6) than those in many contemporary radical prostatectomy studies. The average operative time decreased from 195 minutes (min) in the first 100 patients to 131 min in the last 100 patients, robotic console time decreased from 165 min to 92 min respectively. This decrease in times was noted despite progressively FIGURE 11. Suturing of Dorsal Venous Complex. The dorsal venous complex (blue-arrow head) is controlled by overrunning suture of 2-0 vicryl on RB1 needle. The urethro-sphincter complex (yellow-arrow head) is identified and excluded in the suture. FIGURE 12. Patient Characteristics.
8 404 M. Bhandari and M. Menon. FIGURE 13. K-M Curve: Overall Biochemical Recurrence-Free Survival (BRFS). FIGURE 14. K-M Curve: Biochemical Recurrence-Free Survival (BRFS) by Preoperative PSA. the individual vessels after removal of the prostate, the apical margin rate decreased to 1.5% in patients with T2 disease. Biochemical recurrence Eighty one patients of the 2077 patients with a median follow up of 68 weeks and mean follow up of 82 weeks (range 4-260weeks) had a biochemical recurrence. The BCR rate was 3.9% with the median time to recurrence of 32 weeks (mean 54 weeks, range 0-263weeks) (24). The biochemical recurrence free survival (BRFS) probabilities at 1, 3 and 5 years are 97%, 93% and 92% respectively. Time to BCR and BRFS probabilities are represented in the Kaplan- Meir curves for overall BRFS (Figure 13), by preoperative PSA (Figure14), Organ confined status (Figure15) and Pathological Gleason score (Figure16). On multivariable analysis, preoperative PSA, pathologic Gleason score, percent tumor volume and non-organ confined status were significant factors affecting time to biochemical recurrence. Return of continence 95.2% of patients were continent at the end of 12 months. We considered patients to be conti- FIGURE 15. K-M Curve: Biochemical Recurrence-Free Survival (BRFS) by Organ confined status. FIGURE 16. K-M Curve: Biochemical Recurrence-Free Survival (BRFS) by Pathology Gleason.
9 VATTIKUTI INSTITUTE PROSTATECTOMY (VIP) AND CURRENT RESULTS. 405 nent if they were not using any pads or if they used a safety liner for security reasons. About 26 % patients were totally dry at the time of catheter removal. 55 % of our patients were dry at 4 weeks postoperatively. Only 1.1% of patients required the use of 2-3 pads per day at the end of 12 months. Of these, 4 had collagen injections and 3 opted to have artificial urinary sphincters. The mean pre-operative IPSS and Quality of Life scores (7.7 and 1.66) were significantly more than the post operative values.(6.5 and 1.5, P <0.002 and <0.02). Incontinent patients had a higher rate of anastomotic stricture (6.6% vs 0.71 %) or post-operative radiation therapy (9.09% vs 2.41%). Return of potency 42% of patients underwent standard nerve sparing on both sides. 25% of patients had a unilateral veil of Aphrodite with contralateral standard nerve sparing. 33% of patients underwent a bilateral incremental nerve sparing operation. Patients undergoing bilateral veil of Aphrodite had significantly better return of potency than patients with conventional nerve sparing surgery (Figure 17). In patients with no pre-operative erectile dysfunction (SHIM>21), intercourse was reported in 70 and 100 percent of the patients undergoing bilateral veil nerve-sparing surgery at 12 and 48 month follow-up respectively, although only half of these patients attained normal SHIM score off medication. Post-operative potency rates in patients with no-, mild- and moderate erectile dysfunction preoperatively were analyzed. As expected, potency rates were higher in patients who had no erectile dysfunction pre-operatively. This trend was seen in patients undergoing both, standard or veil of Aphrodite (unilateral or bilateral) nerve-sparing procedures. Regardless of pre-operative erectile function, patients undergoing veil of Aphrodite (unilateral or bilateral) nerve-sparing had better potency outcomes than patients undergoing conventional nerve-sparing prostatectomy (Figure 18). Complications Our analysis of perioperative complications reveals a low incidence of complications. The mean hospital stay for patients undergoing VIP is 1.1 days with 97.6% of patients being discharged home within 48 hours. There were 5.8% unscheduled postoperative visits, mostly for urinary retention following early catheter removal. We have never had to transfuse any patient intraoperatively and our postoperative transfusion rate is 1.5%. The most disturbing complication in our series is symptomatic postoperative urinary leaks (1.8%). Because we use an intraperitoneal approach, these patients develop significant urinary peritonitis. Clinical presentation in such patients is very dramatic. Although half these patients were managed conservatively with nasogastric decompression and bowel rest, the other half needed CT guided drainage of urinomas and prolonged Foley catheterization. Only 0.8% patients had Clavien grade 2 [25] postoperative complications requiring any intervention. Overall, VIP in our hands is a very safe procedure with a major complication rate of 1.5%. FIGURE 17. Erectile Function Postoperatively: Different Nerve Sparing Techniques. FIGURE 18. Comparison of Baseline Erectile Function and Postoperative Outcomes.
10 406 M. Bhandari and M. Menon. CONCLUSION Radical retropubic prostatectomy has evolved over the last three decades to a precise, sophisticated procedure with minimal mortality and excellent surgical outcomes. Our own experience suggests that equally good results can be obtained with robotic assistance. Our technique, Vattikuti Institute Prostatectomy (VIP) continues to evolve with experience, much as open radical prostatectomy does. In our hands, the veil nerve-sparing offers superior erectile function than conventional nerve-sparing surgery without compromising cancer control. It is our preferred technique in potent men with low-or moderately aggressive prostate cancer. ACKNOWLEDGMENTS We thank Alok Shrivastava for illustrations and Fred Muhletaler in preparation of the manuscript. REFERENCES AND RECOMMENDED READINGS (*of special interest, **of outstanding interest) BILL-AXELSON, A.; HOLMBERG, L.; RUT- TU, M. et al: Radical prostatectomy versus watchful waiting in early prostate cancer. N. Eng. J. Med., 352: 1977, WALSH, P.C.; LEPOR, H.; EGGLESTON, J.C.: Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate, 4: 473, WALSH, P.C.; MARSCHKE, P.; RICKER, D. et al: Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology, 55: 58, GRAEFEN, M.; WALZ, J.; HULAND, H.: Open retropubic nerve-sparing radical prostatectomy. Eur. Urol., 49: 38, ABBOU, C.C.; SALOMON, L.; HOZNEK, A. et al: Laparoscopic radical prostatectomy: preliminary results. Urology, 55: 630, GUILLONNEAU, B.; VALLANCIEN, G.: Laparoscopic radical prostatectomy: the Montsouris technique. J. Urol., 163: 1643, MENON, M.; SHRIVASTAVA, A.; TEWARI, A. et al: Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J. Urol., 168: 945, ** *12. * **15. ** MENON, M.; TEWARI, A.; PEABODY, J. et al: Vattikuti Institute prostatectomy: technique. J. Urol., 169: 2289, AHLERING, T.E.; SKARECKY, D.; LEE, D. et al: Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J. Urol., 170: 1738, PATEL, V.R.; TULLY, A.S.; HOLMES, R. et al: Robotic radical prostatectomy in the community setting the learning curve and beyond: initial 200 cases. J. Urol., 174: 269, SMITH, J.A. Jr.: Robotically assisted laparoscopic prostatectomy: an assessment of its contemporary role in the surgical management of localized prostate cancer. Am. J. Surg., 188: 63, KAUL, S.; BHANDARI, A. et al: Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study. Urology, 66: 1261, MENON, M.; KAUL, S. et al: Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes and conventional nerve sparing and prostatic fascia sparing technique. J. Urol., 174: 2291, SARANCHUK, J.W.; KATTAN, M.W.; ELKIN, E. et al: Achieving optimal outcomes after radical prostatectomy. J. Clin. Oncol., 23: 4146, MENON, M.; SHRIVASTAVA, A. et al: Vattikuti institute prostatectomy: contemporary technique an analysis of results. Euro. Urol., 51: 648, MYERS, R.P.: Detrusor apron, associated vascular plexus, and avascular plane: relevance to radical retropubic prostatectomy-anatomic and surgical commentary. Urology, 59: 472, TEWARI, A.; PEABODY, J.O.; FISCHER, M. et al: An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy. Eur. Urol., 43: 444, TAKENAKA, A.; MURAKAMI, G.; SOGA, H. et al: Anatomical analysis of the neurovascular bundle supplying penile cavernous tissue to ensure a reliable nerve graft after radical prostatectomy. J. Urol., 172: 1032, COSTELLO, A.J.; BROOKS, M.; COLE, O.J.: Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int., 94: 1071, KIYOSHIMA, K.; YOKOMIZO, A.; YOSHIDA, T. et al: Anatomical features of periprostatic tissue and its surroundings: a histological analysis of 79 radical retropubic prostatectomy specimens. Jpn. J. Clin. Oncol., 34: 463, LUNACEK, A.; SCHWENTNER, C.; FRITSCH, H. et al: Anatomical radical retropubic prosta-
11 tectomy: curtain dissection of the neurovascular bundle. BJU Int., 95: 1226, VAN VELTHOVEN, R.F.; AHLERING, T.E.; PELTIER, A. et al: Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology, 61: 699, MENON, M.; SHRIVASTAVA, A.; SARLE, R. et al: Vattikuti Institute Prostatectomy: a singleteam experience of 100 cases. J. Endourol., 17: 785, STEPHENSON, A.J.; KATTAN, M.W.; EAS- THAM, J.A. et al: Defining biochemical recurrence of prostate cancer after radical prostatectomy: a proposal for a standardized definition. J. Clin. Oncol., 24: 3973, CLAVIEN, P.A.; SANABRIA, J.R.; STRAS- BERG, S.M.: Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery, 111: 518, 1992.
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Allure medspa
201, Shree Krishna, Opp. Laxmi Industrial Est., Near Fun Republic. New Link Road, Andheri (W), Mumbai - 400053,Maharashtra, India
If your skin texture is uneven and rough and you are looking for a solution to even it out, laser skin resurfacing might be a solution for you. The specialty of this treatment is that the laser treats only a fraction of tissues at time, leaving the surrounding area untouched.This results in rapid healing, replacing the old and tired cells ultimately making your skin plump, clean and glowing.Read More
Dr Ashok Pandey Trinity Multispecialty Clinic
Shop No. 1, Rahul Apt, Opp Bank of Hyderabad. Marve Road, Malad (West)., Mumbai - 400064,Maharashtra, India
Carbon dioxide lasers have been in use for many years to treat different skin conditions. A new generation of carbon dioxide lasers use very short-pulsed light energy (ultra-pulsed) or continuous light beams that are delivered in a scanning pattern to remove thin layers of skin with minimal heat damage to the surrounding structures. These lasers are used to treat wrinkles, scars, warts, linear epidermal nevi (birthmarks), rhinophyma (enlarged oil glands on the nose) and other skin conditions.
Carbon dioxide laser resurfacing is usually performed on an outpatient basis, using local anesthesia in combination with orally or intravenously administered sedative medicines. The areas to be treated are numbed with a local anesthetic. (General anesthesia might be used when the entire face is treated.) A partial-face laserabrasion takes 30 to 45 minutes, and the full-face treatment takes between 90 minutes to two hours.
Finesse Skin Clinic
Shop No 4, Onkar Bldg, Opp Oberoi Mall Filmcity Road, Goregaon East, Mumbai - 400097,Maharashtra, India
Laser360 stimulates new collagen to grow, which improves your skins texture and tone to fight fine lines and wrinkles.Read More
Sujay Hospital
25, Gulmohar Park, Gulmohar Rd. Juhu Scheme Vile Parle W, Mumbai - 400049,Maharashtra, India
If you have scars on your skin and if you are looking for a virtually pain free treatment to heal you skin and give it a chance to rebuild itself, then a Fractional Laser Treatment is ideal for you.Read More
Krasa Clinic
3 407, 1st Floor, Shiv Darshan Opposit Mini Panjab Hotel 33rd Linking Road, Bandra West, Mumbai - 400050,Maharashtra, India
Laser skin resurfacing is far more effective than surgical methods like face-lift and dermabrasion. Also since the treatment works on shedding skin layers, bringing the healthier and brighter layer up, the result is a glowing, smooth, scar-free skin.Read More
Inamdar Hospital
Hospital Building S. No, 15 Fatima Nagar, Pune - 411040,Maharashtra, India
The laser skin resurfacing uses Co2 fraction laser. The therapist targets damaged skin spots. The specialty of this treatment is that the laser treats only a fraction of tissues at time, leaving the surrounding area untouched.Read More
Dr Kalpana Sarangi
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Laser skin resurfacing uses a specially crafted beam of thermal energy that breaks down and removes only the very outer layers of the area of skin you want to treat. This leaves the skin more even as well as encouraging new skin to grow with a healthier look.Read More
Dr Rekha Sheth
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Popularly known as Fraction CO2, this laser resurfacing treatment is extremely useful in what is called Spider Veins. CO2 fractional system is known as a safer alternative to its previous cousins.Besides clearing wrinkles and scars, the Co2 fraction laser treatment can aid in the rejuvenation process of the skin.Read More
Dr. Vishrut Newaskar
3 407, 1st Floor, Shiv Darshan Opposit Mini Panjab Hotel 33rd Linking Road, Bandra West, Mumbai - 400050,Maharashtra, India
The laser skin resurfacing has a lots of benefits. It removes scars and brown spots. It brings out the renewed skin and gives a healthy glow. It is virtually a pain-free treatment.Read More
Anshuman Manaswi Clinic
, Mumbai - ,Maharashtra, India
Laser skin resurfacing, also know as a laser peel, laser vaporization and lasabrasion, can reduce facial wrinkles, scars and blemishes. Newer laser technologies give a new level of control in laser surfacing, permitting extreme precision, especially in delicate areas.Read More
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How much does Laser Skin Resurfacing surgery cost in Maharashtra, India? Check Laser Skin Resurfacing before and after images, Laser Skin Resurfacing reviews, Laser Skin Resurfacing price, Question and Answers, Book Appointment Online in India. Compare from 17 Laser Skin Resurfacing Centers, Hospitals, Clinics & Doctors from India.

subset: commoncrawl


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The first one that I attended was the Full Moon Supper Club. It started out on the full moon months ago, but due to the moon phases, it happened to be held during new moon time last month. This one is held at a volunteer host's home each month. In August it was hosted by local foodie extraordinaire Lisa Rose Starner. Each month Tori O'Haire of The StarvingArtist creates a masterpiece meal based on the food of a country. Last month it was Brasil ($40.00 fee); in September it will be the cuisine Basquaise of Navarre, Spain ($42.00 fee including a wine tasting). Each guest brings their own place setting including glassware.
The other supper club that I attended was located at the old Knapp Farmhouse in Grand Rapids. It was a spectacular summer evening that night, and we ate in the spacious yard. It is a plant-based supper club, which means that the food is vegan. I don't know how many of the 35 or so attendees were vegan, but the food was delicious. There was a surprising amount of variety. For this one, the hosts provides the dishware, and the guests provide the food and beverages.
Full Moon Supper Club
Plant Based Supper Club


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Oh my god it is beautiful. It is the most glorious thing I have ever seen in my life, I need it to complete my soul and cement my happiness… this bag shall rule over all of the other bags. Turquoise leather with a large leopard print pony skin panel and a removable strap made of chain and leather, it is truly a thing of substantial caliber. My heart race increases as I click on it, choosing it alone from among the ranks of lowly polyester blended tat, all neatly presented in tile formation across my screen. It has become clear to me by now that this gorgeous little piece would go with anything, smart, casual, fancy dress it would go, I just know it. My palms perspire as I click the add to bag button… the items in there have a total cost of £177. A dress with a thick petticoat layer in a neon tribal print at £98 tops the list, a moment of weakness…deleted. A Boy London T-shirt at £49….gone. All that remains is you, sweet bag, you alone are destined for a place in my life. You alone have been chosen to join my celestial collection of eclectic accessories; the illustrious holographic clutch, the renowned Vintage Mulberry, the splendid silver glittery round shoulder bag and the ridiculous menagerie of enormous earrings. For all of them I fought to resist, fought to remain abstinent from shopping, spending, going on a…..a spree.
Two words that will get us more worked up than finding an oiled up Channing Tatum waiting for us in the shower are "Shopping Spree". Our pupils dilate, we take a shallow, faltering breath, we grip the edges of our laptops and think of England as we prepare to hit that "Pay Now Securely" button and ready ourselves for our ecstasy comes to an exultant climax. But there's a problem… its slap bang in the middle of the month..and you are, once more, poor as shit til pay day. Alas, the collection you have built up in that online shopping basket over the last hour or so cannot be yours. After all you had that night out at the weekend, you bought that book that you probably won't have time to read, that lunch last week when you forgot to prepare anything at home, not to mention your Gym Membership and Phone Contract. God damn our incredible ability to spend faster than we save. But its so EASY, you click a little button here, tick a box there and two passwords later you've spent £45 on a pair of novelty sunglasses with flamingos on them, a T-Shirt featuring a cat pun and a scarf you don't actually even like that much. I mean obviously we all forget our passwords here and there and end up having to use CAPS LOCK, symbols, numbers, the Deathly Hallows and the One Ring to create a new one. Now, as much as this is a total ball-ache, it does often somehow manage to deter me from my spending habits, slowing down the depletion of my bank balance to a rate I can almost keep up with. But there are times when you will find something in particular, be it a book, a dress, a rare original DC Print of Jennifer Walters mid-transformation (She-Hulk for you non-nerds out there), you end up like Gollum, rubbing your hands together, eyes like saucers whispering "I must have the precious" to yourself over and over again. Sure, every few seconds you will come to and realize that you have none of the money, and should probably ignore this absolute diamond for the sake of your future self who will want a beautiful pair of limited edition Irregular Choice Sequinned Kitten heels instead.
So you force yourself to forget. It's almost like a breakup because you had your sights set on a beautiful future with your precious, you could see the photos together, the holidays you could go on, the compliments you would receive from envious party-goers. Due to internet 'cookies', you'll see them everywhere you go, on the Facebook Sidebar, in the ads when you are trying to stream the latest episode of 'Game of Thrones' on your preferred pirating website (no judgement here, we all do it). Its painful seeing them out there in public as though nothing has changed between you, acting nonchalant when all you want is to scoop them up into your open arms and never let them go. You clear your cookies, and your internet history for good measure. 'Just forget about it', your mind says, but your heart can't let go just yet. You find yourself creeping back to ASOS.com just for a look, just to see if the price has dropped, whether there are any left in stock. Of course there they are, looking as glamorous as ever, surrounded by their mediocre friends who make them look even better than before. Eventually the memories fade, and life moves on, you find yourself taking joy in all things free; walks in the park, sunshine and birdsong, dinner with friends. One fateful day you brave checking your bank balance and find a TRIPLE DIGIT for the first time in weeks, and all hell is about to break lose. You have no option… you …. must… SPEND.
So you make a day of it. You pick Saturday (just like everyone else) to go out armed with your smallest shoulder bag (room for key, phone, card and fags only), flat shoes and sharpened elbows ready to give a bitch a black eye if she even touches that clutch bag before you get there. You arrive in your local town center and one of two things will happen. Either you will go out and all your shopping dreams will come true, you will find endless bargains, that vintage shop will have a 1950s velvet prom dress made for you, there will be a sale on at Topshop and only YOUR size is left and you will get so many taster samples of food that you skip lunch and spend the money on shoes. Alternatively nothing will fit and the one thing that does is a totally ludicrous neon orange neoprene playsuit with scuba zip detailing which you would probably buy, wear once and regret it so much you donate it to a local charity shop where some crazy old lady will buy it and wear it in the streets with her pink dyed hair and her enormous 90s platform trainers asking for spare change to feed her thousands of cats. There is no rhyme or reason to a bad shopping day, but it can happen to the best of us, just remember, with that failure comes the promise of a better run next time, with double the budget (YAAAAY). People may say that society is becoming increasingly materialistic, and honestly I'm inclined to agree. As Carrie Bradshaw once said "I like my money right where I can see it… Hanging in my closet". It is true that money can't buy you happiness, but it can buy you lots and lots of shoes and bags and shit, and that's a good start.


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5 Solutions to All of Your Eyebrow Emergencies
When your eyebrow game is strong, you feel like you can take on the world. However, when something goes amiss in that department, it can feel like the end of the world. Have no fear: No matter what kind of emergency you're faced with, there's a quick-fix solution, and celebrity brow expert and founder of The BrowGal Tonya Crooks has them all.
Scroll through for the answers to your biggest brow dilemmas!
The good news is brow tints usually start to fade by the two-week mark. Right when you get home, saturate a cotton pad with toner, and start scrubbing to lift some of the excess colour. Then, just go with it. "Just embrace it because trying to reverse the process will run the risk of doing more damage," Crooks says.
In an effort to get perfect arches, it's easy to go overboard. If you've gone too far, Crooks says there's no need to break out the makeup remover. Just clean off your spoolie brush on a paper towel, and brush through your brows to blend out the colour. If you need to fix the edges, a clean finger will do the job.
Or maybe you're just not at home and you've forgotten to pack your eyebrow definer. "The backup is you can always try using a neutral taupe eye shadow," Crooks says. Not an eye shadow wearer? Your contour powder may work. Just be sure to test a small section to ensure that the colour isn't too warm for your brows.
To ensure your brows remain picture-perfect always, pick up one of the eyebrow pencils below!
Burberry Effortless Eyebrow Definer ($33)
The BrowGal Skinny Eyebrow Pencil ( $23 ) ($0)
CK One Colour Brow Pencil & Gel Duo ($22)
Charlotte Tilbury Brow Lift Three-Way Shape, Lift, & Shade Eyebrow Pencil ($29)
Lorac Pro Brow Pencil ( $19 ) ($0)


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The Founder
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Followers at DDM Los Angeles give their tribute to Venerable Master Sheng Yen
From 5th to 14th February 2009, faithful followers gathered at the Chan Hall of Dharma Drum Mountain in Los Angeles (DDM Los Angeles) to prostrate to the Sakyamuni Buddha, to participate the Buddha-name Recitation Dharma Rituals and to give the last warmest tribute to Venerable Master Sheng Yen.
Through the Internet video, on 5 February about 60 followers attended in the Chan Hall to simultaneously watch the Encoffin and Sealing the Coffin Ceremony. On 7 February, about 55 followers watched the Cremation Ceremony of the Master. On 14 February, about 85 followers gathered in the Chan Hall to watch the Commemoration and Ash-Burial Ceremony in memory of Venerable Master Sheng Yen.
(translated by Jin Yang/edited by DDM Australia Editing Team)
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Dharma Drum Mountain World Center for Buddhist Education
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text: Ahhh! So this is a blog huh? I have always been skeptical of starting a blog but here I am! So here's the scoop: I am newly engaged, yay! With starting the planning process I figured, hey why not incorporate my love for vintage into the wedding?! Love is an understatement, I cannot get enough of antiques! I spend a lot of time hunting through antique stores and flea markets. My favorite finds are dressers and chairs that to most people look like dirty, broken furniture. To me, it's charm and potential. I take these pieces and with a little elbow grease and TLC they become something beautiful! So why not incorporate this passion of mine into my special day?! Making a long story short I want to share my experiences with new brides, future brides, and anyone else that shares the same love for antiques!


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Jupiterimages/Comstock/Getty Images
Peanut butter and chocolate are classically paired flavors and brownies with peanut butter sauce are yet another variation of this combination. Peanut butter itself needs to be thinned and made into a sauce before it can complement the brownies. Making and keeping peanut butter into a pourable consistency takes just a couple of ingredients and a few minutes to create.
Place the sugar, corn syrup and butter or shortening in a saucepan over medium heat. Stir until it just begins to boil.
Remove pan from heat. Stir in peanut butter and milk and return to heat.
Stir until sauce just begins to boil again and peanut butter is melted into sauce. Remove from heat.
Add the vanilla to the sauce and stir. Serve warm over the fresh baked brownies.


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Logo Maker animal / pet logo - Cat Duo
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Sunday, April 27, 2014
Mother's Day Gift Idea
Mother's Day is only 2 Sundays away! If you haven't already, check out my previous post for these easy DIY Pendants. They really only take an afternoon to finish and are very affordable. You can add them to a necklace, key chain or even turn them into magnets!
Labels: crafts, Just for Fun
1 comment:
Welcome to the stunning selection of sensual gifts available exclusively here online from Imogen Lingerie. Uniquely personal, intimate gifts luxuriously packaged and presented in a beautiful, reusable box as thoughtfully crafted as the contents.ReplyDelete
unique gifts
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text: There are two kind of altars. Devotional altars and functional altars. A devotional altar is a sacred space dedicated entirely to one or many deities. There is usually a figurine or image representing that deity. In it you place the offerings, prayers and stuff for that deity. It can be simple or heavily ornameted. Ornaments… Continue reading What IS an altar? + a photo of mine.


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|Job Details
|Job Id/Status:
|Job Posted/Updated:
|Dental Front Office
|Job Type:
|Days of Week:
|Mon, Tue, Wed, Thur, Fri
|Buford, GA 30519
|Dental office in Buford seeks a qualified front office receptionist to become a part of our team! We offer family, surgical, cosmetic and orthodontic services in our practice and pride ourselves on treating our patients like family. We are all team players and know that each employee is an integral part of keeping the office running smoothly. Responsibilities and qualifications include: *2 Years experience in the dental field, with knowledge of Dentrix. *Positive attitude *Appearance (professional, clean, neat, meets company standards.) *Knowledge of insurance processes and treatment planning. *Professionalism and leadership *Independent problem solver (i.e. can respond quickly to emails and patient account questions) *Sense of responsibility to the practice and patients. *Triaging multiple patients and phone calls, this includes scheduling and monitoring appointment book. *Can verify insurance unassisted (i.e. Ortho, Implants, Crowns.) This includes full breakdowns of insurance. *Knowledge of dental treatment plan sequencing and CDT dental codes. *Great attitude and doesn't get flustered in high-stress situations. *Non-Smoker We all love working here and hope that you will love it just as much! It is for this reason that a working interview will be given for candidates who demonstrate the qualities above. We can't wait to meet you!


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Mateschitz: the pits must not interfere
Red Bull Racing owner Dietrich Mateschitz says there is no number one or number two driver in his team and that the team should not interfere in the driver rivalry.
Mateschitz, speaking to the German newspaper Kleine Zeitung, said he was not involved in the controversial Silverstone decision to take an upgraded front wing off Mark Webber's car and give it to team mate Sebastian Vettel just ahead of qualifying, after Vettel's own wing had been damaged in the final session of free practice.
Mateschitz said that Red Bull should not have a number one driver because the philosophy was "not in keeping with my understanding of racing." He added: "Our two drivers know that, a) they have to beat the other and, b) they still need each other to take points away from the competition. Both drivers have cars to exactly the same standard and the wing problem at Silverstone was the first exception."
Mateschitz said he thought it "unlikely" that his warring drivers would let in a rival to win the championship but "would not rule it out. And if it happens, we're talking about racing." The energy drink magnate said that while it was regrettable that the Silverstone controversy erupted in the way that it did in the media, Webber had done nothing wrong.
The championship heads to Vettel's home race at Hockenheim this weekend with Red Bull Racing trailing McLaren by 29 points in the constructors' championship and Webber 17 points adrift of Lewis Hamilton in the drivers' championship. The Red Bull drivers are separated by just seven points.


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…including us.
Hadas Gold reports in Politico that President Trump will welcome members of the conservative media for a small reception at the White House on Monday: "Among those attending: One America News Network, The Daily Caller and Breitbart, as well as some columnists and talk radio hosts." If all goes according to plan, Power Line will be represented there too and I will have more later. The occasion of the reception, as I understand it, is the completion of Trump's first 100 days in office.
Gold quotes Sean Spicer: "We've definitely done our fair share of meetings with mainstream reporters. Once in a while it's important to appreciate the folks who have really covered the president fairly and covered a lot of issues ignored by mainstream media."
As we round into our fifteenth anniversary online next month, I think it's fair to say that we have aspired to cover the president fairly and have certainly covered a lot of issues ignored by the mainstream media. But I would concede that I'm not an impartial judge of our virtues.


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Are you probing trying to find a decent adjustable bed in North Carver MA? Continue reading for crucial info on exactly how to acquire the ideal adjustable beds in North Carver MA.
Which Are The Best Adjustable Beds in North Carver MA?
In addition to replacement mattresses that are adjustable you can also buy sleeper sofas that are adjustable. A few of the price tags for all these items are below just so you can get a very clear choice concerning what you can expect to finance for an adjustable bed, mattress or frame:
Pillow Top Reversible Mattress
The Empress mattress is literally a popular pillow top mattress regarding adjustable beds utilizing the workhorse 312 coil innerspring. It comes with an off white Damask cover having a open quilt design. Pillow top is on both sides of the mattress for prolonged use. Begins at $500 and climbs in cost with the size.
Premier Mattress Bed
Fully customizable options and features. Innerspring comfort possibilities in soft, medium or extra firm. The optimal sleep position regarding the head and feet is within reach with simple to use hand controls and the Premier's Swift-Adjust motors. The Premier style comes standard with a high-density foam foundation plus a heavy-duty base crafted with material that definitely will not warp, break or squeak. Starts off at around $1500 for a plush top twin and obviously goes steeper with price. One of the most steeply-priced one I checked out was for almost $4k and it was a king Firm Talalay Latex Core with Plush Quilted Cover. Conceding that you buy a twin bed for sure its going to cost much less compared to a giant king bed! Know that these things need to be kept in mind in cases where comparing beds, as well as how much room you have.
Did you find this short article useful? Feel free to distribute this article with your friends and family, that live in North Carver MA. You never know when they might be planning to purchase an adjustable bed frame in North Carver MA.
Video: Adjustable Beds Prices in North Carver
See below for more related info:


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Rajouri: The Bharatiya Janata Party (BJP) on Friday asserted that the Handwara incident was an attempt by `Pakistani agents` to defame the Indian Army and the Jammu and Kashmir Government.
"Pakistani agents and supporters in Jammu and Kashmir are hard at work to disgrace the Indian Army and the state government. The Indian Army has been protesting and saving the people of Jammu and Kashmir from Pakistan for the past 20-30 years," BJP MLA Ravinder Raina told ANI here.
Stating that the personnel of the Indian Army have been sacrificing themselves to save the lives of the civilians in the region, he added that `paid` Pakistani agents in the area were at work to defame the nation and its soldiers.
"Even the girl has admitted that no Army man misbehaved with her. This is a conspiracy to defame the Indian Army," Raina added.
As per reports, the girl has denied that she was molested by an Army man and accused two local youths of hatching a conspiracy.
Meanwhile, an uneasy calm prevailed in the Valley as the police continued to place restrictions in several parts for the third day.
Chief Minister Mehbooba Mufti had earlier said that she had spoken to Defence Minister Manohar Parrikar, who assured her that the guilty would not be spared.
"I spoke to Lt General DS Hooda and Defence Minister Parrikar and they have assured me that an enquiry has been set in place and that those responsible will be punished. The family of the victims will also be compensated," she added while stating that the incidence of violence was unfortunate and should never have happened.


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Since the announcement of new community programs at Mobile World Congress App Planet, community-led BlackBerry® Developer Groups have continued to sprout up everywhere! Currently there are active groups all over the world, including Zurich, Berlin, Buenos Aires,Tel Aviv, with many more set to launch. If there isn't one in your area already, you can bet there will be one soon.
By becoming a member of a BlackBerry Developer Group, you can:
- Meet a local community with shared interests in learning, networking and support for BlackBerry development platforms.
- Receive platform and program updates from Research In Motion® (RIM®).
- Get access to exclusive discounts for Developer Certification Exams.
- Receive exclusive discounts to select BlackBerry® Developer Events and Conferences.
Become a Group Manager! Start a new group!
We are also looking for new Group Managers around the world! Visit the BlackBerry Developer Groups page to find out more information, including additional benefits to which Group Managers are entitled and how to start a new Developer Group in your city if one does not already exist.


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Call one of our team today
Rental Enquiries:0800 525 184
Landlord Enquiries: 0800 634 0834
We delighted to announce we are back on air on the Smooth Radio UK Digital platform – tune in on your digital radio or television to hear our advert.
Do you fancy a new start for a new year? Why not rent a purpose built retirement property through Girlings and take advantage of our New Year deals? You can choose from a select number of retirement properties throughout the UK, offered to you on a 2 Year Assured Shorthold Tenancy, with special lower monthly rents for the duration of the tenancy.


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Thursday, January 12, 2012
wintery dots
you probably recognize this polka dot dress as the one in my first post from the dominican. i kinda love it so i wanted to wear it again, this time more winterized. i found my vintage sweater at a local consignment shop and thought it the perfect oversized accompaniment to this sheer and flirty dress and of course pairing it with my little black booties. i really like it when a favorite piece can be worn in lots of different ways and even in different seasons.
and speaking of seasons, boy howdy, this been the craziest winter! yesterday-bare legs, today-snow on the ground. crazy i tell you. and now i'm going to drink my third cup of coffee :)
boots-c/o jcpenney
Posted by amanda at 9:02 AM
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Berkeley, in cooperation with Lambeth Council, has developed a Masterplan for the Oval and Kennington Development Area (OAKDA). This covers the Oval Gas Works and 16 surrounding parcels of land.
We have been consulting with the local community since January 2015 to understand your vision and aspirations for the area. At the end of 2015 a draft masterplan was released to the community for consultation. Berkeley then worked to collate the feedback and to then agree amendments to the proposals. This culminated in the submission of the Masterplan to Lambeth for formal consideration in May 2016.
The Masterplan evolved through expert analysis, engagement with the Council, the local community and other key stakeholders over a period of two years. However since then there have been further developments and analysis.
Berkeley has been in detailed pre-application discussions with Lambeth Council and the Mayor of London on the Oval Gas Works site, located at the heart of the Masterplan area, since May 2016. The need to deliver affordable housing on the site has been at the forefront of discussions with the authorities and as such has created an opportunity to revisit the affordable housing strategy across the wider Masterplan to deliver more of the much needed affordable housing.
As a result amendments have had to be made to the existing Masterplan and Berkeley has drafted a Masterplan Addendum to illustrate changes necessary to achieve the revised affordable housing target, as well as increasing other public benefits.
Berkeley is wholeheartedly committed to working in partnership with the local community and we are keen for residents to be able to review the key aspects of The Masterplan Addendum document in more detail. As such, Berkeley held a public exhibition to showcase the amendments to the OAKDA Masterplan on Monday 23rd and Tuesday 24th October.
Since the exhibition held in October Lambeth's Cabinet Member for Planning, Regeneration and Jobs has expressed in principle support for the OAKDA Masterplan and Addendum Document on 27th December 2017.
To view the full version of the Cabinet Member Report please follow the link below:


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This is the scientific classification of Garcinia Gummi-Gatta. Saptrees are a species of the tropical fruit that produce HCA (hydroxycitric acid), and that is the Energetic and main component in Garcinia. Once you take hca your body will experience considerably less hunger because of the hunger suppression. Saptrees can even have an effect on the s… Read More
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Remember KENYA
- Keep The Date Free – commit to sing the anthem at 1pm on February 28th.
- Ee Mungu Nguvu Yetu – learn the anthem! All three stanzas! English or Kiswahili, it's up to you!
- Network, network, network – get your family, friends, neighbours to sing along as well! United we stand.
- You, me, united – this is an inclusive initiative. There's more that unites us than divides us.
- Amani – keep the peace, respect each other, respect our National Anthem, respect our flag, respect our country.
We welcome the interest from the media! Partner with us to unite our country!
Post our Stand For Kenya on your blog
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You are currently browsing the monthly archive for January 2008.
I find that almost everyone who has had cancer wants to fight back. I guess personalities play into it. Ann has not had cancer but she has been affected by the cancer of her friends. Marie has had cancer and she has just completed her treatments but she is ready to fight back. Both have organized teams for relay at their churches. It is a good thing because during the past week I have heard of so many more who have been diagnosed with cancer. Julie has melanoma. Jack and Jerry have prostate cancer. Bobbi and Duane have cancer too. When is it going to be stopped! Can we relay enough?
The American Cancer Society is doing a fabulous job with research. We are making giant steps toward stopping cancer but in the meantime cancer is trampling right through lives.
Lord, I pray that you intervene in this fight. In your way, find a way to stop cancer. Amen!
Well, the last Christmas decoration has been packed. The Bowl game has been played and lost. 2008 is here! I promised myself that as soon as all that was done I would start on Relay for Life. I am so excited! I have been going to events like Relay University in October and executive committee meetings since November. Of course, all that was around funerals—both on the same day– for my cousin Sophia who had leukemia and my dear church friend Fayette who had cancer. I get so excited about the work that Relay accomplishes and then, pow! The reason we have to keep fighting back hits hard!
I imagine that you can sit there and count on your fingers the people you know personally who have been affected by cancer. This year the Relay motto is
celebrate, remember, and fight back!
Will you help me again? Please!!!!! I want to raise over $2500 this year. Even more if possible! Cancer needs to be stopped! I am begging you to help!!!!!!
The site is secure for online donations. I really encourage you to donate that way. It cuts out the processing costs of cash/checks. The URL is http://www.events.cancer.org/rflgreenvillesc. You can click on the John Knox team and then my name to contribute. If you want to donate in memory or honor of someone please include their name either on the site or on your check.