Francesco Cattaneo

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula

INTRODUCTION There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes. AIMS To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training. RESULTS The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations. CONCLUSIONS In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Wunderlich’s syndrome: Three cases of acute spontaneous renal bleeding, conservately treated

Wunderlichs syndrome is a clinical condition defined as a spontaneous renal bleeding of non traumatic origin, contained within the Gerotas fascia. Wunderlichs syndrome is rare. Spontaneous bleeding of kidney tumors, either benign or malignant, represents the more common causes. Classically it presents with acute flank pain, tender palpable mass and clinical hemodynamic deterioration. These symptoms are defined as the Lenks classic triad. We present three cases of spontaneous renal bleeding.

Slings in surgery of genuine stress incontinence

PurposeTo summarize the available evidence concerning efficacy and safety of standard mid-urethral sling (SMUS) operations for the treatment of stress urinary incontinence (SUI).Methods and resultsA non-systematic literature review was carried out in order to collect the available evidence concerning efficacy and safety of SMUS operations for the treatment of SUI. According to the data of our prior meta-analysis, patients receiving SMUS had significantly higher overall and objective cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations. Patients undergoing SMUS and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms and had a higher reoperation rate. Patients treated with retropubic SMUS had slightly higher objective cure rates than those treated with transobturator tape (TOT); however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of some complications. Meta-analysis demonstrated similar outcomes for TOTs. With regard to the novel mini-sling, another meta-analysis from Abdel-fattah et al. demonstrated that repeat continence surgery and de novo urgency incontinence were significantly higher in the patients treated with mini-slings.ConclusionPatients treated with retropubic tape (RT) experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective. The use of RT was followed by objective cure rates slightly higher than TOT and by higher risk of complications. The novel mini-slings do not seem to be more effective than the SMUS.

Fluorocholine PET/CT predicts skeletal progression, skeletal event and cancer specific survival in patients with biochemical relapse for prostate cancer

PURPOSE The aim of our study is to evaluate the prognostic impact of 18F-Choline (FCh) positron emission tomography (PET)/computed tomography (CT), CT alone and methylene diphophonate bone scan (MDP-BS) in prostate cancer (PCa) patients with biochemical relapse. METHODS We retrospectively selected 58 patients who underwent, between June 2010 and February 2013, both FCh-PET/CT and MDP-BS within a maximum time interval of 5months. All patients had a biochemical PCa recurrence after radical prostatectomy and/or radiation therapy. Two independent observers reviewed FCh-PET/CT and MDP-BS images. The bone window of CT portion from FCh-PET/CT was separately assessed. Time to progression (TTP), skeletal event free survival (SES) and cancer specific survival (CSS) were defined as the length of time between imaging and progression of disease, skeletal related events and cancer specific mortality, respectively. A patient based and a K agreement analysis was used to compare the findings of all three imaging modalities. Kaplan-Meier and log-rank analysis were computed for survival assessment. A multivariate Cox regression analysis was used to identify the independent predictors for TTP. RESULTS Bone metastases were detected in 22 (38%) patients at FCh-PET/CT, in 27 (47%) at MDP-BS and in 24 (41%) at CT. The agreement between FCh-PET/CT and MDP-BS, CT and MDP-BS, and FCh-PET/CT and CT were moderate/fair (respectively, k: 0.474, 0.267 and 0.424; all p<0.05). After 38months (IQR: 27-54months) of follow-up, 33 (57%) patients had a new recurrence of disease, 12 (21%) had skeletal related events and 19 (33%) died. Three subjects (5%) were lost during the observational period. At survival analyses, a worse TTP, SES and CSS were found in patients with a positive FCh-PET/CT at bone level than those with a negative scan (all p≤0.05). Conversely, any significant difference in TTP, SES and CSS was found for patients with both a positive MDP-BS and CT scan. At univariate analysis, a positive FCh-PET/CT at skeletal level was associated with all events (all p<0.05). However, only a positive FCh-PET/CT at any site was an independent prognostic variable of TTP (HR: 3.08; CI 95%: 1.85-9.05; p=0.04). CONCLUSIONS PET/CT should be preferred to CT and BS in patients with prostate cancer with bone metastasis because it allows a better stratification of TTP, SES and CCS compared to CT and BS.

Complex cystine kidney stones treated with combined robot-assisted laparoscopic pyelolithotomy and intraoperative renoscopy

Introduction: Cystinuria, a rare autosomal recessive disease characterized by a defect in cystine renal reabsorption, can often determine complex cystine renal calculi, leading to important complications such as urinary obstruction, urinary infections, and impaired kidney function. Complex kidney stones can have a difficult management and can be very arduous to treat. Case description: We present the case of a 20-year-old Jeowah’s witness woman with complex cystine renal stones treated with combined robot-assisted laparoscopic pyelolithotomy and intraoperative renoscopy. Conclusions: The combination of robot-assisted laparoscopic pyelolithotomy and intraoperative renoscopy can be useful to achieve an immediate high stone clearance rate also in complex renal stones. This combined technique could be indicated to minimize intraoperative bleeding. Moreover, it can also be used in pediatric cases or when there is no ureteral compliance. However, this strategy can be performed only in hospital referral centers by expert surgeons.

The Role of Lymph Node Dissection in the Treatment of Bladder Cancer

Lymph node dissection (LND; PLND: pelvic LND) is an essential component of radical cystectomy (RC) for bladder cancer (BC). However, the optimal anatomical extent of LND and its potential therapeutic role are still controversial: as we will explain, the extent of LND dissection is a predictor of survival and local recurrence but what is an adequate extension is still unclear. Moreover, there is large uncertainty about the role of surgery in patients with clinically-positive nodes. In this review we will provide a synthesis of the available evidence on this highly debated topic. Overall, the studies presented in this work support the idea that extended lymphadenectomy could provide optimal diagnostic and possibly therapeutic results in cN- patients. In cN+ patients, post chemotherapy surgery may be considered especially in subjects who have a good response to CHT, although definitive evidence is still needed. Finally, the final results of randomized trials are eagerly awaited to draw definitive conclusions of the role of PLND in BC.

Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies

OBJECTIVE To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. RESULTS Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2, R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. CONCLUSION OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

Endourologic Diagnosis and Robotic Treatment of a Giant Fibroepithelial Polyp of the Ureter

Abstract Background: Fibroepithelial polyps (FEPs) are a rare cause of ureteropelvic junction (UPJ) obstruction. Radiologists and urologists are not always confident with this disease because of its rarity, complex diagnosis, and heterogeneity of the available treatment options. Case Presentation: We present the endourologic diagnosis and the robotic management of a ureteral polyp close to the left UPJ. A 16-year-old woman with a 12 years history of left lumbar pain was referred to our Center. A computed tomography scan detected a left hydronephrosis with no signs of obstructions at MAG-3 scintigraphy. The endourologic evaluation revealed a giant FEP of the left ureter, which was removed surgically with a videolaparoscopic robot-assisted approach. Conclusion: Considering that conventional radiologic imaging techniques can hardly detect a ureteral FEP, an endourologic study of the urinary tract is mandatory to directly observe the polyp. The mini-invasive treatment of ureteral FEPs is feasible and safe, and should be considered as first option in young patients.

Positive surgical margins after radical prostatectomy

Positive surgical margins (PSMs) in radical prostatectomy specimens are usually considered a negative prognostic parameter. However, their definition and the management of patients with PSMs remain unclear. The aim of the present review is to define pathological features of PSMs, to report their incidence and risk factors and to update PSMs prognostic meaning and possible treatment modalities. The average incidence of PSMs in contemporary series ranges from 6.5% to 32%. The likelihood of PSMs is influenced by pre-operative PSA (total-PSA and PSA-density), tumor features (volume, grade and stage), previous prostatic surgery (open or TURP), patients’ characteristics (BMI and pelvis shape) and surgeons’ skill. Although PSMs are a predictor of biochemical recurrence, their impact on cause specific survival is highly variable and largely influenced by the tumor Gleason Score. Adjuvant radiotherapy is an effective treatment in PSMs patients but early salvage radiotherapy may be an alternative option that guarantees equivalent survival benefits with less side effects. Further studies are required to define the best candidates to adjuvant or early salvage radiation therapy.