Christian Padevit

Single-centre evaluation of the extraperitoneal and transperitoneal approach in robotic-assisted radical prostatectomy

Abstract Objective. Robotic-assisted radical prostatectomy (RARP) is feasible using either an extraperitoneal (EP) or a transperitoneal (TP) approach. This study reports on the experience of a single hospital using both techniques. Material and methods. From July 2009 to March 2011, 170 patients underwent RARP. EP was chosen in 103 patients and TP in 67. TP was preferred in cases previous mesh hernia repair or if extended lymph-node dissection (LND) was considered necessary. Otherwise, EP was performed; it was preferred in cases of obesity (body mass index (BMI) > 30kg/m2)) or previous intra-abdominal surgery. Results. There were no significant differences in preoperative mean age (64.4 vs 65.6 years), BMI (26.5 vs 26.3 kg/m2) or prostate size (51.8 vs 55.8 cm3) between EP and TP patients. Owing to preoperative selection criteria, prostate-specific antigen levels and the average Gleason score were significantly lower in EP than in TP patients (p < 0.001). Whereas access time and time for anastomosis did not differ significantly (21 vs 19 min, p = 0.11, and 26 vs 24 min, p = 0.36, respectively), overall surgical time was significantly longer in TP (225 vs 191 min, p < 0.001). Blood loss was equal in both groups (EP 276 vs TP 281 ml, p = 0.88). Complication rates were lower in EP (n = 7, 6.8% vs n = 8, 12%, p = 0.024). Time until first defecation and last analgesic treatment were significantly shorter in EP (p < 0.05). Conclusions. The results of the current evaluation underline the clinical advantages of an extraperitoneal approach for RARP. However, a transperitoneal approach is still considered necessary for extended LND or special clincial conditions. Robotic teams should be trained using both approaches.

Pre- and Postoperative Urodynamic Findings in Patients After a Bulbourethral Composite Suspension with Intraoperative Urodynamically Controlled Sling Tension Adjustment for Postprostatectomy Incontinence

OBJECTIVES To compare pre- and postoperative urodynamic findings in patients with a bulbourethral composite suspension and intraoperative urodynamically controlled sling tension adjustment. METHODS AND PATIENTS All data were prospectively collected from 10 patients (mean age 66 years) who successfully underwent bulbourethral composite suspension for moderate to severe postprostatectomy incontinence. Patients were evaluated preoperatively and 3-6 months postoperatively by urodynamic measurements, including urethra pressure profiles (UPPs) and pressure flow studies (PFSs). Clinical outcome was evaluated by patient-reported pad use and questionnaires (ICIQ-UI SF and I-QOL). Intraoperatively sling tension was adjusted under repeated urodynamic measurements of abdominal leak point pressure. Data were evaluated using the Kruskal-Wallis Wilcoxon test. RESULTS Sling implantation was successful in all patients. Pre- to postoperative pad use decreased significantly (P < .005). Five patients were pad-free, 3 used 1 pad, and 2 used 2 pads per day. Continence and quality of life improved significantly (ICIQ-UI SF: pre-op 17 vs post-op 4.9; I-QOL: pre-op 66 vs post-op 91; P < .05 for both). Urodynamic parameters during the filling phase remained unchanged. UPPs revealed a significant increase of the maximal urethral closure pressure (pre-op 40 cm H(2)O vs post-op 58 cm H(2)O) and functional length (pre-op 31 mm vs post-op 40 mm; P < .05 for both). Postoperatively, urodynamic maximal flow rates were slightly reduced from 16 mL/s to 12 mL/s (P = .4). PFSs revealed an unobstructed voiding in all patients. CONCLUSIONS According to the present evaluation, a bulbourethral composite suspension with intraoperative urodynamically controlled sling tension adjustment improves continence without causing prolonged clinically or urodynamically significant voiding obstruction.

Complications of a buried penis in an extremely obese patient

The buried penis syndrome in adults is a rare condition of different aetiologies. Today extreme obesity is considered as a major contributor. We present a case of a 30‐year‐old extremely obese patient (BMI 65 kg/m2) with purulent infection of the penile cavity, a phlegmon of the mons pubis and urinary retention due to a buried penis. Whereas acute complications of a buried penis in obese patients include local infection and urinary retention, chronic problems are undirected voiding, disturbed vaginal penetration and erectile dysfunction. Even though several surgical techniques are described, weight reduction should be primarily preferred.

Successful Removal of a 3.6-cm Long Metal Band Used as a Penile Constriction Ring

INTRODUCTION Penile constriction rings are either used for autoerotic stimulus or to increase sexual performance. Potentially, they can become irremovable and cause urologic emergencies. AIM We describe the successful removal of a 3.6-cm long piece of heavy metal tubing used as a penile constriction ring. METHODS An angel grinder was used to open the metal tubing on both lateral sides. During the cutting procedure, the soft tissue parts were protected by two metal spatulas. Wet towels and cool running water prevented thermal injury. RESULTS After removal of the band, no iatrogenic injury was visible and the further recovery of the patient remained uneventful. Postoperatively, one of the surgeons suffered from conjunctivitis of the left eye possibly due to metal sparks. CONCLUSION Depending on the constricting object, heavy-duty technical equipment might become necessary for their removal. In such cases, special care should be taken to avoid injury to the patient and the medical crew.

Pre-prostatic tissue removed in robotic assisted lymph node dissection for prostate cancer contains lymph nodes.

Objective: The on-going discussion about extent and best template for pelvic lymph dissection (PLND) motivated us to analyse pre-prostatic tissue (PPT) for lymph nodes and metastases. Materials and Methods: From December 2010 to August 2011 PPT was sent for histopathological evaluation during 80 robotic assisted radical prostatectomies (RARP) and one extended staging lymph node dissection. All patients had either a limited (lPLND, n = 44) or an extended lymph node dissection (ePLND, n = 36). Clinical data were retrospectively analyzed and compared to histopathological findings. Results: Lymph nodes were found in PPT in 10/80 (12.5%) patients after RARP and in the one patient after staging ePLND. Mean number of lymph nodes detected in PPT of them was 1.2 (range 1-3). Clinically no differences were found between patients with or without lymph nodes in PPT. In the standard template of either ePLND or lPLND the average number of lymph nodes was 13 (range 2-56). Herein metastases were found in 10 (12.5%) patients after RARP and in the patient after staging ePLND. A metastasis in PPT was only found after staging ePLND. Conclusions: Pre-prostatic tissue might contain lymph nodes that potentially harbour metastases. In the intention to perform the most accurate staging this tissue should be considered for histopathological evaluation.

Robot-Assisted Simple Prostatectomy

The surgical management for severely enlarged prostate glands (generally >80 g) in men with symptomatic BPH remains a challenge. Simple prostatectomy is considered the standard of care, if laser enucleation or vaporisation is not available. Although open simple prostatectomy is an effective and durable treatment option, it is associated with the risk of severe bleeding, transfusion and prolonged hospital length of stay. The retropubic transvesical technique (Freyer, Br Med J 2:868, 1912) and the suprapubic transcapsular operation (Millin et al. Lancet 1:381–385, 1949) are still widely accepted as the gold standard. However, the blunt dissection of the adenoma from the capsule, especially in the apical and sphincteral areas makes this procedure very invasive. Therefore minimal invasive approaches have been introduced as laser techniques, conventional laparoscopy and robotic assisted technology.

Minimalinvasive Vasektomie und Vasovasostomie

DieerstenVasektomienwurdenEndedes 19. Jahrhunderts nicht aus Sterilisationsgründen durchgeführt, sondern zur BehandlungvonProstataerkrankungen,zur Verbesserung einer bestehenden Impotenz oder gar zur Lebensverlängerung. In den 20erund 30er-Jahren des 20. JahrhundertswarenAspekte derEugenikund der sozialenKontrolle hauptsächliche Indikationen zur Durchführung einer Vasektomie. Die Vasektomie zur Sterilisation wurde erst in den 1960er-Jahren populär. Trotzdem sind weltweit nur knapp 3% aller Männer vasektomiert. Der chinesischeArztDr. Li Shunqiang wendete 1974 erstmals die minimalinvasiveNon-Skalpell-VasektomiealsMethode der Sterilisation anund steigerte somit dieAkzeptanz diesesVerfahrens deutlich [1]. Rund 5% aller verheirateten Paare im fortpflanzungsfähigen Alter entscheiden sich für eineUnterbindung alsMittel der Wahl zur Verhütung. Aufgrund der

Urethrale Anastomose bei orthotopem Blasenersatz nach roboterassistierter radikaler Zystektomie (RARC) an deutschsprachigen Robotikzentren

INTRODUCTION Following robot-assisted radical cystectomy (RARC) and extracorporeal reconstruction, robotic continuous suture techniques and those using open or robotically pre-positioned single sutures are used for the urethroneovesical anastomosis. METHODS 62 German-speaking robotic centres were asked in an online questionnaire whether they carried out RARC. Following an affirmative answer further questions were put to the form of the neobladder and the technique of the urethrovesical anastomosis. RESULTS 80% of the online questionnaires were answered. 44% (n=22) of these centres perform the RARC. According to the answers, given all of the centres but one perform an extracorporeal construction of the neobladder [Studer bladder 73% (n=16), Hautmann bladder 18% (n=4), others 9% (n=2)]. After reconstruction 36% (n=8) of the teams perform a completely open surgical anastomosis with pre-positioned sutures, 24% (n=5) close the anastomosis in a single knot technique using robotically pre-positioned sutures and 40% (n=9) use continuous sutures during the intracorporeal reconstruction or after re-docking the robot. CONCLUSION According to this questionnaire to German-speaking centres the most common anastomotic technique following extracorporeal reconstruction, mostly a Studer bladder, is that of the pre-positioned single knot sutures. This offers the advantage that a re-docking of the robotic cart is unnecessary. In contrast, however, to robotically performed suturing, there must be enough space in the open procedure to surgically tie-off the sutures of the anastomosis.