Carlos Roberto Giúdice

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results

AbstractObjectivenTo present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra.Materials and methodsFrom June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799–1802, 2007).ResultsPatients’ age range was from 3 to 82xa0years (mean 51.2). Stricture length ranged from 1 to 3xa0cm (mean 1.78). After a mean follow-up of 17.6xa0months, 95.6xa0% of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty.ConclusionPreservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Abordaje quirúrgico de la estenosis de anastomosis vesicouretral posprostatectomía radical

INTRODUCTIONnVesicourethral anastomotic stricture following prostatectomy is uncommon but represents a challenge for reconstructive surgery and has a significant impact on quality of life. The aim of this study was to relate our experience in managing vesicourethral anastomotic strictures and present the treatment algorithm used in our institution.nnnPATIENTS AND METHODSnWe performed a descriptive, retrospective study in which we assessed the medical records of 45 patients with a diagnosis of vesicourethral anastomotic stricture following radical prostatectomy. The patients were treated in the same healthcare centre between January 2002 and March 2015. Six patients were excluded for meeting the exclusion criteria. The stricture was assessed using cystoscopy and urethrocystography. The patients with patent urethral lumens were initially treated with minimally invasive procedures. Open surgery was indicated for the presence of urethral lumen obliteration or when faced with failure of endoscopic treatment. Urinary continence following the prostatectomy was determinant in selecting the surgical approach (abdominal or perineal).nnnRESULTSnThirty-nine patients treated for vesicourethral anastomotic stricture were recorded. The mean age was 64.4 years, and the mean follow-up was 40.3 months. Thirty-three patients were initially treated endoscopically. Seventy-five percent progressed free of restenosis following 1 to 4 procedures. Twelve patients underwent open surgery, 6 initially due to obliterative stricture and 6 after endoscopic failure. All patients progressed favourable after a mean follow-up of 29.7 months.nnnCONCLUSIONSnEndoscopic surgery is the initial treatment option for patients with vesicourethral anastomotic strictures with patent urethral lumens. Open reanastomosis is warranted when faced with recalcitrant or initially obliterative strictures and provides good results.

Incidence and location of positive surgical margins following open, pure laparoscopic, and robotic-assisted radical prostatectomy and its relation with neurovascular preservation: a single-institution experience

To evaluate whether robotic-assisted radical prostatectomy (dvRP) provides adequate local control of the disease, incidence of positive surgical margins (PSMs) obtained with dvRP was compared with that of laparoscopic radical prostatectomy (LRP) and with that of open radical retropubic prostatectomy (RRP) performed in a single institution by the same surgeons. We also studied whether neurovascular bundle preservation modified PSM rates. The records were retrospectively reviewed from electronic medical data, and three groups of 100 patients were organized. Groupxa01 included 100 patients who underwent RRP prior to the incorporation of minimally invasive techniques. Groupxa02 included the first 100 patients who underwent LRP, and groupxa03 was made up of the first 100 patients who underwent dvRP. All surgical specimens were analyzed by the same pathologist. We used the technique described by Patel etxa0al. for dvRP. LRP was performed using a five-trocar extraperitoneal approach as previously published by the authors. RRP was performed using retrograde dissection as described by Walsh etxa0al. The final decision of preserving neurovascular bundles was made during surgery. Using D’Amico’s risk classification, the dvRP group had a lower percentage of patients with low risk (dvRP versus LRP pxa0=xa00.017; dvRP versus RRP pxa0=xa00.0108). No statistically significant differences were found within high- and intermediate-risk groups. A higher percentage of patients with pT3 disease was found in the dvRP group compared with the RRP group (pxa0=xa00.0408). There were no statistically significant differences regarding PSMs among groups (RRP: 25, LRP: 14, dvRP: 18), although when we compared the total number of PSMs we found that the dvRP group had 18 PSMs versus 21 and 50 PSMs for LRP and RRP, respectively. All three groups had more PSMs located posterolaterally. There was a higher percentage of nerve-sparing procedures in the dvRP group (dvRP: 91 patients, LRP: 47 patients, RRP: 5 patients) (pxa0<xa00.0001). No statistically significant differences were found in the PSM rates between the three techniques analyzed. The number of nerve-sparing procedures in the dvRP group was statistically higher. However, this preservation did not modify PSM rates.

V1-12 ROBOTIC-ASSISTED RADICAL PROSTATECTOMY AND CONTINENT URINARY STOMA (MITROFANOFF) IN A 7 YEAR CHILD.

INTRODUCTION AND OBJECTIVES: Urethrectomy with appendicovesicostomy is a treatment option for low stage urethral cancer. We present a novel minimally-invasive surgical approach which allows for robotic appendicovesicostomy to be performed simultaneously with open urethrectomy. METHODS: A 71 year-old man presented with clinically-localized squamous cell carcinoma of the urethra. He underwent a traditional open urethrectomy with simultaneous robotic-assisted bladder neck closure, omental J flap interposition, and appendicovesicostomy. The robot was side-docked to allow for a perineal surgeon to work in tandem with the robotic surgeon. RESULTS: Total operating room time was 391 minutes. Robotic console time was 281 minutes. Length of stay was four days. There were no complications, and no secondary procedures were required. Final pathology demonstrated T2 squamous cell carcinoma with negative margins. At 6 months follow up, the patient is continent and cancer-free. CONCLUSIONS: Simultaneous extirpative surgery and minimally-invasive urinary tract reconstruction is possible for patients with urethral cancer. Side-docking the robot allows for two surgical teams to work concurrently. This approach may be applicable to other procedures requiring both open perineal and laparoscopic intraabdominal access.

La incidencia de márgenes quirúrgicos positivos tras prostatectomía radical asistida por robot: ¿tiene la experiencia del cirujano influencia en todos los estadios patológicos?

OBJECTIVEnThe aim of this study is to analyze the clinical and surgical features of patients who underwent robotic-assisted radical prostatectomy (RARP) at our institution, and the impact of the surgeons experience in the oncological results related to pathological stage.nnnMATERIAL AND METHODSnAn analysis of 300 RARP consecutively performed by the same urologist was conducted. Patients were divided into 3 groups of 100 patients in chronological order, according to surgery date. All patients had organ-confined clinical stage. Variables which could impact in positive margins rates were analyzed. Finally, positive surgical margins (PSM) in regard to pathological stage and surgeons experience were compared and analyzed.nnnRESULTSnNo significant differences were found in variables which could impact in PSM rates. The overall PSM rate was 21%, with 28% in the first group, 20% in the second, and 16% in the third (P = .108). Significant lineal decreasing tendency was observed (P = .024). In pT2 patients, the overall PSM rate was 16.6%, with 27%, 13.8%, and 7.3% in each group respectively (P = .009). A significant difference was found between group 1 and group 3 (P = .004). In pT3 patients, the surgeons experience was not significantly associated with margin reductions with an overall PSM rate of 27.7% (28.2%, 28.6%, and 26.7% in each group respectively).nnnCONCLUSIONSnClinical and surgical features in our patients did not vary over time. We found a significant reduction of PSM related to surgeons experience in pT2 patients. Contrariwise, the margin status remained stable despite increasing experience in pT3 patients.