Andrea Sorcini

Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest

The topics covered in this section include renal, prostate, bladder and testicular cancer. As can be seen, these contributions come from all over the world and are of interest for several reasons. For example, the first paper, from the USA, describes the management of RCC with vena caval and atrial extension, using minimal access as against median sternotomy with circulatory arrest. Other more unusual subjects include RCC of native kidneys in renal‐transplant recipients and radical prostatectomy in patients with HIV.

Neonatal scrotal haematoma: mimicker of neonatal testicular torsion.

To describe the clinical features of neonatal scrotal haematoma and distinguish them from those of neonatal testicular torsion.

Vascular reconstruction in urology

Vascular reconstructive surgery in urology includes techniques of revascularization of the renal artery for renovascular hypertension or ischemic nephropathy in situ or extracorporeal renal artery reconstruction. The indications for aortorenal bypass, extra-anatomic bypass, or simultaneous aortic substitution and renal revascularization are based on the cause, location, and extent of the vascular lesion. Techniques of bench surgery mainly depend on location of the renal artery disease and availability of autologous graft material.

Unidirectional barbed suture versus standard monofilament for urethrovesical anastomosis during robotic assisted laparoscopic radical prostatectomy

PURPOSE V-Loc™180 (Covidien Healthcare, Mansfield, MA) is a new unidirectional barbed suture that may reduce loss of tension during a running closure. We evaluated the use of the barbed suture for urethrovesical anastomosis (UVA) during robotic assisted laparoscopic prostatectomy (RALP). Time to completion of UVA, post-operative anastomotic leak rate, and urinary incontinence were compared in patients undergoing UVA with 3-0 unidirectional-barbed suture vs. 3-0 Monocryl™ (Ethicon, Somerville, NJ). MATERIALS AND METHODS Data were prospectively collected for 70 consecutive patients undergoing RALP for prostate cancer between November 2009 and October 2010. In the first 35 patients, the UVA was performed using a modified running van Velthoven anastomosis technique using two separate 3-0 monofilament sutures. In the subsequent 35 patients, the UVA was performed using two running novel unidirectional barbed sutures. At 7-12 days postoperatively, all patients were evaluated with a cystogram to determine anastomotic integrity. Urinary incontinence was assessed at two months and five months by total daily pad usage. Clinical symptoms suggestive of bladder neck contracture were elicited. RESULTS Age, PSA, Gleason score, prostate size, estimated blood loss, body mass index, and clinical and pathologic stage between the 2 groups were similar. Comparing the monofilament group and V-Loc™180 cohorts, average time to complete the anastomosis was similar (27.4 vs. 26.4 minutes, p = 0.73) as was the rate of urinary extravasation on cystogram (5.7 % vs. 8.6%, p = 0.65). There were no symptomatic bladder neck contractures noted at 5 months of follow-up. At 2 months, the percentage of patients using 2 or more pads per day was lower in the V-Loc™180 cohort (24% vs. 44%, p < 0.02). At 5 months, this difference was no longer evident. CONCLUSIONS Time to complete the UVA was similar in the intervention and control groups. Rates of urine leak were also comparable. While the V-Loc™180 was associated with improved early continence, this difference was transient.

Comparison of positive surgical margin rates in high risk prostate cancer: open versus minimally invasive radical prostatectomy.

OBJECTIVE We compared positive surgical margin (PSM) rates for patients with high risk prostate cancer (HRCaP) who underwent open radical retropubic (RRP), robotic (RALP), and laparoscopic (LRP) prostatectomy at a single institution. MATERIALS AND METHODS We performed a retrospective review of our prospectively maintained IRB approved database identifying prostate cancer patients who underwent RRP, RALP, or LRP between January 2000 and March 2010. Patients were considered to have HRCaP if they had biopsy or final pathologic Gleason score ≥ 8, or preoperative PSA ≥ 20, or pathologic stage ≥ T3a. A positive surgical margin (PSM) was defined by the presence of tumor at the inked surface of the specimen. Patients who received neoadjuvant hormonal therapy and those who underwent a perineal prostatectomy were excluded from the study. RESULTS Of the 445 patients in this study, surgical technique for prostatectomy included RRP (n = 153), RALP (n = 152), and LRP (n = 140). PSM rate for the three groups were not different: 52.9% RRP, 50% RALP, and 41.4% LRP, (p = 0.13). The PSM rate did not differ when comparing RRP to a combined group of RALP and LRP (p = 0.16). Among patients with a PSM, there was no statistical difference between the three groups in terms of the number of patients with a pathologic stage of T3 or higher (p = 0.83). On univariate analysis, a higher preoperative PSA value was associated with a positive margin (p = 0.04). CONCLUSION In this HRCaP series, the PSM rate did not differ based on the surgical approach. On univariate analysis, patients with a higher preoperative PSA value were more likely to have a PSM.

Novel Technique Prevents Lymphoceles After Transperitoneal Robotic-assisted Pelvic Lymph Node Dissection: Peritoneal Flap Interposition

INTRODUCTION To determine the efficacy of our novel technique to prevent lymphocele formation after pelvic lymph node dissection (PLND) after robotic-assisted radical prostatectomy (RARP) using the existing peritoneum of the bladder. TECHNICAL CONSIDERATIONS We evaluated 155 consecutive patients undergoing RARP with PLND over 24 months. Group A included the first 77 patients with PLND using standard technique (no peritoneal flap). Group B included the subsequent 78 patients (1 patient excluded) with PLND and peritoneal interposition flap. The peritoneal interposition flap is created by rotating and advancing the peritoneum around the lateral surface of the ipsilateral bladder to the dependent portion of the pelvis and fixing it to the bladder itself. A cystogram was performed in 91% of the patients 7-14 days after the surgery. Lymphocele formation rates were compared (based on symptoms, cystogram findings, and radiographic confirmation). RESULTS The 2 groups were statistically equivalent in terms of prostate-specific antigen, age, blood loss, body mass index, Gleason score, prostate size, pathology, or heparin use. Lymphocele formation occurred in 9 of 77 (11.6%) group A patients and in 0 of 77 group B patients (P = .003). Mean time to lymphocele detection in group A was 30.4 days. Mean follow-up in groups A and B were 383.97 and 379 days, respectively (P = .91). CONCLUSION Strategic rotation and fixation of a peritoneal flap around the lateral aspect of the bladder during transperitoneal RARP with PLND is a novel technique to prevent lymphocele formation. Given the sample size and single institutional study, a prospective, randomized, multi-institutional trial is planned.

Pure Laparoscopic Donor Nephrectomy: 3-Year Experience and Analysis of a Refined Technique to Maximize Graft Function

PURPOSE Strategies for vascular control and limiting warm ischemia time (WIT) vary between institutions for laparoscopic live donor nephrectomy (LLDN). We refined our technique and retrospectively determined whether it safely provides an allograft of comparable quality to published series. PATIENTS AND METHODS Fifty consecutive LLDN between February 2003 and November 2006 were reviewed. Key technical aspects include placing the perfused kidney and transected ureter entirely within an endocatch bag, with the string externalized through an extended lateral port site incision. Vessels are then controlled with clips, or a Satinsky clamp for right sided veins. The extraction incision is completed and the bag immediately withdrawn and placed on ice. WIT ends with perfusion with cold UW solution. RESULTS The series includes 42 left and 8 right kidneys. 13/50 (26%) demonstrated anatomical complexity (more than one artery, vein and/or ureter). Average operative time was 178 minutes. Average WIT was 128 seconds. Conversion to open surgery occurred in two patients, one to define challenging anatomy, and another for hemorrhage from the renal artery stump. Average blood loss was 76 ml. Average length of stay was 3.6 days. Average recipient creatinine was 1.26 mg/dl at discharge. Delayed graft function occurred in three recipients. ATN/slow normalization of creatinine occurred in four. Graft survival at one year was 96%. CONCLUSIONS The refined technique of LLDN mimics important principles of open donor nephrectomy. Controllable variables which may impact graft function are optimized. WIT is amongst the lowest reported for pure laparoscopy, without increasing complication rates, blood loss, or operative time.

Laparoscopy for the Detection and Treatment of Early Complications from Minimally Invasive Urologic Surgery

OBJECTIVE To evaluate the role of laparoscopy for the detection and management of early postoperative complications after minimally invasive urologic surgery. PATIENTS AND METHODS From October 2003 to September 2008, data were prospectively collected for all patients needing surgical intervention within 21 days after urologic minimally invasive procedures. No patients operated on for a postoperative complication during this period were excluded. Minimally invasive surgical intervention was performed on all hemodynamically stable patients in whom pneumoperitoneum could be established safely. RESULTS A total of 1962 laparoscopic or robot-assisted urologic procedures were performed. In 14 (0.7%) cases, surgical intervention was necessary for postoperative complications. Two patients underwent exploratory laparotomy because of abdominal distention and hemodynamic instability. Laparoscopic surgical intervention successfully diagnosed and treated the remaining 12 patients. There were no conversions to open surgery. No additional trocars were necessary apart from preexisting sites. Two (14%) patients had minor postexploration complications. Mean estimated blood loss was 70 mL (range 50-100 mL). The mean length of hospital stay after exploration was 2 days (range 5 hours-5 days). CONCLUSIONS With surgical expertise, laparoscopic treatment of intra-abdominal complications after minimally invasive urologic procedures can be successfully and safely performed. The advantages of the minimally invasive approach may be preserved.

V6-08 ROBOTIC URETERAL RECONSTRUCTION FOR URETERAL COMPLICATIONS OF KIDNEY TRANSPLANTS

INTRODUCTION AND OBJECTIVES: Robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladders is a challenging surgical procedure. The potentially increased risk of neobladders stone formation consequent to the use of staplers to create the neobladders is still a matter of debate. Robotic staplers have been recently made commercially available. In this prospective study (www. clinicaltrials.gov NCT02665156) we assessed the feasibility, safety and time efficiency of RARC with intracorporeal partly stapled “Padua Ileal Bladder” using robotic staplers. METHODS: Twenty-two consecutive patients with muscle invasive or high grade recurrent urothelial carcinoma of the bladder were treated between March 2016 and October 2016. Baseline, perioperative and follow-up data were prospectively collected and maintained into an IRB approved database. Key steps of surgery include: selection of 45 centimeters of ileum and division of the distal and proximal part of the ileum using robotic staplers; detubularization of the ileal loop; creation of the neo-bladder neck with one stapler load; double folding of the proximal ileal loop using two-three stapler loads; hand-sewing of the posterior neobladders wall with barbed suture; uretero-ileal anastomoses on JJ stents with a modified split-nipple technique; urethroneobladder anastomos is performed according to Van Velthoven; hand-sewing of the anterior neobladders wall with barbed suture. RESULTS: All procedures were successfully completed; open conversion was never necessary. Median total operative time (“skin to skin”) was 270 minutes (IQR:255-295). Operative time was < 300 minutes in all patients but two (345 and 350 minutes, respectively). One patient (4,5%) had wound infection (CLavien grade 1), three patients (13.6%) had Clavien grade 2 complications (blood pack trasfusion, urinary tract infection requiring antibiotics, hypoxaemia requiring oxygen treatment), one patient (4.5%) needed urethral catheter replacement in the OR (Clavien grade 3b) and one patient (4.5%) had acute kidney failure requiring temporary dialysis (Clavien grade 4a). Median hopsital stay was 9 days (IQR 8-11). Three patients (13.5%) required readmission after discharge (Candidaemia requiring medical treatment [Clavien grade 2] and nephrostomy tube insertion in two patients [Clavien 3a]). Overall complication rate was 40.1% and overall severe complication incidence was18.2%; 59.5% of patients did not experience any complication. At a median follow-up of 3 months, no patients developed recurrence, daytime continence rate was 59%. CONCLUSIONS: We first report safety and time efficiency in the use of robotic staplers to create orthotopic neobladder. This preliminary report highlights feasibility of this technique and favorable perioperative and functional outcomes.

126 UNDERUTILIZATION OF IMMEDIATE ADJUVANT INTRAVESICAL CHEMOTHERAPY FOLLOWING TURBT: RESULTS FROM THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP)

INTRODUCTION AND OBJECTIVES: A single peri-operative dose of intravesical chemotherapy (IVC) following transurethral resection of bladder tumors (TURBT) for non-muscle invasive bladder cancer has demonstrated a reduction in recurrence and is recommended by both the American Urological Association and European Association of Urology. A previous study of nationwide claims data from 1997-2004 identified only 0.33% of patients received same day IVC following TURBT. In this study, we investigate whether IVC following TURBT continues to be underutilized. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) user files, a national prospective outcomes-based database designed to measure surgical quality of care, we identified patients undergoing TURBT for small, medium, and large bladder tumors by Current Procedural Terminology (CPT) codes 52234, 52235, and 52240, respectively. We then crossreferenced this group for the CPT code 51720 to identify patients receiving concurrent intravesical therapy. Operative time, length of hospital stay, and perioperative complications were evaluated. RESULTS: From January 1 to December 31, 2010, 1,782 patients underwent TURBT. The median age was 73 years and 74% (n 1326) were male. Based on CPT code, there were 668 (37%) small, 650 (36%) medium, and 464 (26%) large tumors treated. The majority of patients had general anesthesia (84%) and were treated as outpatients (81%). Of all 1,782 patients, only 36 (2%) received concurrent IVC. There was no difference in average operative times (36.8 v. 33.3 mins, p 0.584) or average length of hospital stay (1.5 v 0.3 days, p 0.538) in patients receiving perioperative IVC. In the group not receiving IVC, there were 64 (3.75%) urinary tract infections, 37 (2.1%) incidences of bleeding requiring transfusion, and 10 (0.5%) patients with sepsis or septic shock. There were no reported peri-operative complications in the IVC cohort. CONCLUSIONS: Only 2% of patients received concurrent IVC with TURBT. No added morbidity was observed for patients receiving IVC, although patient selection could account for low perioperative complications in this group. We also acknowledge other limitations of this data set since timing of IVC following TURBT and details regarding specific tumor characteristics and any prior TURBT procedures are not available. In addition, IVC may have been administered and not billed. Despite current recommendations, peri-operative intravesical chemotherapy following TURBT remains underutilized.