Ahmed Ghazi

Multispectral Photoacoustic Imaging of Prostate Cancer: Preliminary Ex-vivo Results.

Objective: The objective of this study is to validate if ex-vivo multispectral photoacoustic (PA) imaging can differentiate between malignant prostate tissue, benign prostatic hyperplasia (BPH), and normal human prostate tissue. Materials and Methods: Institutional Review Boards approval was obtained for this study. A total of 30 patients undergoing prostatectomy for biopsy-confirmed prostate cancer were included in this study with informed consent. Multispectral PA imaging was performed on surgically excised prostate tissue and chromophore images that represent optical absorption of deoxyhemoglobin (dHb), oxyhemoglobin (HbO2), lipid, and water were reconstructed. After the imaging procedure is completed, malignant prostate, BPH and normal prostate regions were marked by the genitourinary pathologist on histopathology slides and digital images of marked histopathology slides were obtained. The histopathology images were co-registered with chromophore images. Region of interest (ROI) corresponding to malignant prostate, BPH and normal prostate were defined on the chromophore images. Pixel values within each ROI were then averaged to determine mean intensities of dHb, HbO2, lipid, and water. Results: Our preliminary results show that there is statistically significant difference in mean intensity of dHb (P < 0.0001) and lipid (P = 0.0251) between malignant prostate and normal prostate tissue. There was difference in mean intensity of dHb (P < 0.0001) between malignant prostate and BPH. Sensitivity, specificity, positive predictive value, and negative predictive value of our imaging system were found to be 81.3%, 96.2%, 92.9% and 89.3% respectively. Conclusion: Our preliminary results of ex-vivo human prostate study suggest that multispectral PA imaging can differentiate between malignant prostate, BPH and normal prostate tissue.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

To validate robot‐assisted surgery skills acquisition using an augmented reality (AR)‐based module for urethrovesical anastomosis (UVA).

Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery

PURPOSE To examine the association between extended-duration prophylaxis (EDP), low-molecular-weight heparin prophylaxis for 28 days after surgery for urologic cancer in patients at high risk of developing a venous thromboembolism (VTE), the risk of VTE, and the complications resulting from VTE prophylaxis. MATERIALS AND METHODS The cohort included 332 patients at high risk for VTE who were surgically treated for urologic cancer from June 2011 to June 2014. Adherence to VTE prophylaxis protocol, VTEs, and complications within 365 days from surgery were tracked. Patients were grouped as follows: (1) per protocol in-hospital prophylaxis with EDP (n = 107), (2) per protocol in-hospital prophylaxis without EDP (n = 42), (3) not per protocol in-hospital prophylaxis with EDP (n = 83), and (4) not per protocol in-hospital prophylaxis without EDP (n = 100). The risk of VTE was compared between the 4 groups using the Cox model, with adjustment for baseline risk factors. RESULTS The rates of VTEs and median times to VTE were 7% and 58 days in group 1, 17% and 44 days in group 2, 17% and 46 days in group 3, and 21% and 15 days in group 4, respectively. Adjusted hazard ratios (HR) for VTE were HR = 0.27 (95% CI: 0.11-0.70) for groups 1 vs. 4; HR = 0.66 (95% CI: 0.25-1.60) for groups 2 vs. 4; and HR = 0.66 (95% CI: 0.29-1.26) for groups 3 vs. 4 with a trend of P = 0.002. The incidence of complications from VTE prophylaxis was not significantly different between the groups, with a rate of 8% in group 1, 17% in group 2, 6% in group 3, and 12% in group 4 (P = 0.33). CONCLUSIONS In high-risk urologic cancer surgery patients, a clinical protocol, with perioperative and EDP, is safe and effective in reducing VTE events.

Complications associated with extraperitoneal robot-assisted radical prostatectomy using the standardized Martin classification.

OBJECTIVE To report and identify the predictors of early and long-term complications in a large series of extraperitoneal robot-assisted radical prostatectomy using the standardized Martin criteria. MATERIALS AND METHODS A total of 1503 patients underwent extraperitoneal robot-assisted radical prostatectomy for the treatment of clinically localized prostate cancer from July 2003 to August 2010 at a tertiary referral center. The median follow-up was 28.9 months. Fishers exact test was used to examine the association of multiple variables in a bivariate analysis with the incidence and types of complications. Independent predictors were also examined in a multivariate analysis using logistic regression models. RESULTS A total of 151 complications were recorded in 127 of 1503 patients (8.45%). Approximately one third (30.5%) were classified as major complications requiring intervention (Clavien grade III and IV). The most commonly encountered complications were lymphocele (1.46%), bladder neck contracture (1.33%), and anastomotic leak (1.20%). The operative time was a significant predictor of all complications and of major complications on multivariate analysis. Surgeon experience was also predictive of complications on multivariate analysis. CONCLUSION Extraperitoneal robot-assisted radical prostatectomy remains an underused alternative approach for the treatment of localized prostate cancer. Its safety profile is equivalent to that of other approaches in experienced hands.

Optimizing the Approach for Lymph Node Dissection during Laparoscopic Radical Cystectomy

BACKGROUND Lymph node dissection (LND) for muscle-invasive bladder cancer is one of the integral steps of radical cystectomy. In addition to staging, adequate LND has been found to alter both the prognosis for and the course of the disease after radical cystectomy. OBJECTIVE To point out several essential steps that provide optimal exposure for LND during laparoscopic radical cystectomy for muscle-invasive bladder cancer. DESIGN, SETTING AND PARTICIPANTS From August 2006 to September 2008, we performed 10 laparoscopic cystectomies with an extended LND using this approach at our institution. Patient and tumor characteristics, the anatomic extent of the LND, the number of lymph nodes examined, and the postoperative complications encountered were evaluated. SURGICAL PROCEDURE Essential steps include (1) a modified five-trocar arrangement; (2) use of a 30 degrees telescope during LND; (3) prior complete mobilization of the sigmoid colon, allowing its retraction using an umbilical tape; (4) accomplishment of most of the bilateral LND from the right side; and (5) performance of LND after removal of the specimen. MEASUREMENTS The primary end points were adequate intraoperative exposure of the template and number of lymph nodes retrieved. The secondary end point was evaluation of postoperative lymph node recurrence as an assessment of a complete LND. RESULTS AND LIMITATIONS Mean total operative time was 512.5 min (range: 420-660), with a mean operative time of 143 min (range: 115-165) for the extended LND. Adequate exposure was successful in all 10 patients. The average number of lymph nodes examined was 25.5 (range: 19-32), with 4 nodes positive for metastasis. No patients had pelvic or lymph node metastasis at a mean follow-up of 14.8 mo (range: 4-30). Limitations included an analysis of a small series of patients. CONCLUSIONS This new approach provides optimal exposure for an adequate laparoscopic LND during radical cystectomy, without any compromise.

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP.

Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant.

Extraperitoneal robotic-assisted radical prostatectomy in carefully selected renal allograft recipients may be feasible in avoiding injury to the renal allograft, transplanted ureter, and ureteroneocystostomy.

A novel approach for a complete laparoscopic nephroureterectomy with bladder cuff excision.

BACKGROUND AND PURPOSE The dilemma in management of the distal ureter and bladder cuff during nephroureterectomy (NU) for transitional-cell carcinoma (TCC) of the upper urinary tract has delayed the development of a completely minimally invasive approach to NU in cases of TCC. Our aim is to present our technique of a purely laparoscopic nephroureterectomy performed entirely through laparoscopic ports, which mimics established principles of open surgical nephroureterectomy with bladder cuff excision. Precluding the needed for patient repositioning, complex endoscopic procedures either before or after nephrectomy and leaving the bladder cuff defect to heal spontaneously. PATIENTS AND METHODS Patient positioning and trocar arrangement are similar to those of radical nephrectomy. The simple addition of a 5 mm trocar in the lower abdomen (midline or lateral to the rectus muscle, according to patient build) allows the surgeon to adequately dissect the distal ureter, excise an adequate bladder cuff, and suture the bladder defect in a watertight manner without the need for transurethral and intraureteral instrumentation as well as intraoperative repositioning of the patient. RESULTS Eight cases were successfully treated. The operative time ranged from 110 to 200 minutes (mean 157 min). The median time for catheter removal was 7 days; in one patient, catheter removal was delayed to 15 days because of bladder extravasation. Average hospital stay was 10.2 days. During a mean follow-up of 12.1 months, three patients had Ta bladder recurrence, and one patient had local recurrence. CONCLUSIONS A complete NU with bladder cuff excision can be accomplished using this approach, with early results comparable to the gold standard of open surgery with the simple addition of a trocar.

Delayed Detection of Injury to an Ectopic Ureter of a Duplicated Collecting System following Laparoscopic Radical Prostatectomy for Early Organ-Confined Prostate Cancer

In the era of early detection of organ-confined prostate cancer, guidelines support the fact that many patients will not need an aggressive staging work-up, to avoid unnecessary investigations. This strategy may lead to serious repercussions in rare incidences. We present a rare case of urinary extravasation following laparoscopic radical prostatectomy caused by injury of the upper pole ectopic ureter of an undetected duplex system on 1 side, an injury which is the first of its kind in laparoscopic urology.

Renal hilus clamping with tourniquet during laparoscopic partial nephrectomy.

in LPN. For the laparoscopic setting most authors described clamping with laparoscopic Satinsky or bulldog clamps [4,9,10]. In this article we describe the technique of achieving renal vascular occlusion using vessel loop tourniquet for LPN. We will focus on the detailed operative technique, our suggested technical modifications and then discuss its advantages over the laparoscopic Satinsky or bulldog clamps. field to be successful [2]. Despite evolving techniques and technologies aimed to facilitate LPN [3], duplication of open surgical principles including transient renal vascular clamping, can be viewed as standard in most cases [3–8].