Gagan Gautam

Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi.

Introduction: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2–3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm2) complete staghorn calculi. Patients and Methods: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. Results: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089–6,012 (mean 4,800) mm2. 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5–5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.

Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: Time reduction and cost benefit

Study Type – RCT (randomized trial)

Robot-assisted partial nephrectomy: current perspectives and future prospects.

The widespread adoption of laparoscopic partial nephrectomy (LPN) has been curtailed by its technical complexity. With the introduction of robotic technology, there is a potential for a shorter learning curve for minimally invasive nephron-sparing surgery (NSS). Initial published data on robot-assisted partial nephrectomy show promising perioperative outcomes comparable to large LPN series performed by highly experienced laparoscopic surgeons. Intraoperative parameters (operating room time, warm ischemia time, and blood loss) and short-term oncologic results demonstrate that this technique, unlike LPN, has a relatively short learning curve. Economic factors, as well as the necessity of an experienced bedside assistant, present the potential shortcomings of the procedure.

Posterior Rhabdosphincter Reconstruction During Robot-assisted Radical Prostatectomy: Critical Analysis of Techniques and Outcomes

Many centers have recently implemented posterior rhabdosphincter reconstruction (PRR) into robot-assisted radical prostatectomy (RARP) with the objective of earlier continence recovery. We comprehensively review the anatomic and functional changes occurring post prostatectomy along with the reconstructive techniques and published outcomes of PRR. Several case control studies show a better continence rate within the first 3 months, whereas the only randomized control trial presents a conflicting conclusion. Unfortunately, all reported studies lack uniform surgical technique, continence definition, and measures, making comparison difficult. Although initial results appear favorable, the true continence benefit of PRR remains debatable and requires further research.

Application of Ice Cold Irrigation During Vascular Pedicle Control of Robot-Assisted Radical Prostatectomy: EnSeal Instrument Cooling to Reduce Collateral Thermal Tissue Damage

BACKGROUND AND PURPOSE Energy-based hemostasis of the prostatic vascular pedicles (PVP) during robot-assisted radical prostatectomy (RARP) may cause collateral thermal injury to adjacent neural tissue and has been shown to negatively impact sexual function recovery. The unique engineering design of the EnSeal(®) (Ethicon, Cincinnati, OH) has been demonstrated to limit collateral thermal tissue damage to <1.0 mm. Use of tissue and instrument cooling before and during device activation may potentially further reduce thermal spread. As such, we sought to evaluate the collateral tissue effects of EnSeal with or without cold saline irrigation (CSI) during PVP control. PATIENTS AND METHODS The EnSeal Trio device was used for PVP control in 20 consecutive men undergoing bilateral, non-nerve-sparing RARP. Ipsilateral vascular pedicles were randomly selected to EnSeal plus CSI (<4 °C) application to the tissue before and during device activation or EnSeal alone. The primary end point was the distance of thermal injury from the inked margin using both hematoxylin and eosin (H&E) and terminal transferase uridyl nick end-labeling (TUNEL) apoptosis staining. A mean of three measurements was taken for each pedicle. Pathologic analysis was performed by a single, blinded uropathologist. RESULTS Mean distance of thermal injury from the inked margin using H&E staining was 0.31 mm (range 0.15-0.40 mm) and 0.98 mm (range 0.7-1.2 mm) for the EnSeal plus CSI and EnSeal alone, respectively (P < 0.0001). TUNEL staining also demonstrated lateral tissue damage of 0.39 mm (range 0.2-0.5 mm) and 1.12 mm (range 0.9-1.3 mm), respectively (P < 0.001). No complications related to hemostasis or postoperative bleeding were observed in the study. CONCLUSIONS The hemostatic properties of EnSeal work effectively when submerged in CSI. Adjacent thermal tissue damage is significantly minimized with the addition of CSI. This may have a beneficial impact on nerve preservation and sexual function outcomes after RARP.

Histopathological predictors of renal function decrease after laparoscopic radical nephrectomy.

PURPOSE Radical nephrectomy is inevitably associated with a variable renal function decrease. We assessed the association of histopathological parameters in nonneoplastic renal parenchyma with the renal function decrease after radical nephrectomy. MATERIALS AND METHODS We evaluated 32 male and 17 female patients with a mean age of 55.9 years who underwent laparoscopic radical nephrectomy. Using the Cockcroft-Gault formula we calculated the estimated glomerular filtration rate preoperatively and at last followup at a mean of 19.7 months. The study end point was the percent change in the estimated glomerular filtration rate from baseline, defined as (absolute change/baseline) × 100. Three histological features in the nonneoplastic parenchyma were assessed by a renal pathologist, including global glomerulosclerosis, arteriosclerosis and interstitial fibrosis/tubular atrophy. For glomerulosclerosis assessment the percent of affected glomeruli was determined. Arteriosclerosis or the extent of arterial luminal occlusion was graded into 4 groups, including 1-0% to 5%, 2-6% to 25%, 3-26% to 50% and 4-greater than 50%. However, due to small patient numbers groups 1 and 2, and 3 and 4 were condensed, and AS was statistically evaluated as 0% to 25% or greater than 25%. Interstitial fibrosis/tubular atrophy was evaluated as absent/present. RESULTS The mean estimated glomerular filtration rate decreased 31% from 122 to 85 ml/minute/1.73 m(2) after surgery (p < 0.0001). The percent change in the estimated glomerular filtration rate was associated with glomerulosclerosis extent (p = 0.034). For each 10% increase in glomerulosclerosis the estimated glomerular filtration rate decreased by 9% from baseline. The extent of arteriosclerosis or the presence of interstitial fibrosis/tubular atrophy did not correlate with the estimated glomerular filtration rate decrease. CONCLUSIONS Glomerulosclerosis severity in nonneoplastic parenchyma can predict the rate of renal function decrease after radical nephrectomy. This histopathological parameter should be assessed in all tumor nephrectomy specimens, given that preserving renal function is important for quality of life and clinical outcome in patients with renal cancer.

Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters.

An elderly gentleman, on urinary drainage catheter for 3 months developed a purple discoloration of the urinary bag with the urine inside remaining clear. He was found to have a urinary tract infection with a strain of E. coli manifesting as a rare clinical entity reported in literature as the “Purple urine bag syndrome”.

The current role of renal biopsy in the management of localized renal tumors.

Introduction: In the current era of nephron-sparing surgery (NSS) for localized tumors, pretreatment tissue biopsy is being revisited and re-evaluated. Whether a renal biopsy can supplement imaging investigations to change patient management is a subject of current research. Materials and Methods: We performed a database search in PubMed for manuscripts from 1988 to 2008 using the appropriate keywords. Manuscripts were selected according to their relevance to the current topic and incorporated into this review. Results: Preoperative renal biopsy has been utilized to effectively distinguish between benign and malignant tumors localized to the kidney with minimal additional morbidity attributable to the procedure. Tissue diagnosis can also potentially grade renal tumors and uncover unusual malignancies. Although its acceptance remains limited, with fear of false negative results, bleeding and tumor seeding, its ability to influence management decisions has been demonstrated in literature. Conclusions: The role of preoperative renal biopsy for localized renal tumors is likely to increase rapidly in the coming times. With the expanding scope and utilization of NSS, this diagnostic modality will find increased applicability and acceptance in individualizing management protocols in the future.

Laparoscopic pyeloplasty using the postanastomotic dismemberment method: technique and results.

BACKGROUND AND PURPOSE Despite excellent results, widespread acceptance of the laparoscopic dismembered Anderson-Hynes pyeloplasty (AH) is hampered by its steep learning curve. Laparoscopic nondismembered pyeloplasty techniques, although simpler, have not matched the results of AH. We have been using a technical modification of AH to combine its excellent outcome with technical ease of nondismembered pyeloplasties. We describe the procedure and results of laparoscopic postanastomotic dismemberment (PAD) pyeloplasty for primary ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS PAD technique involves an initial partial division of the dilated pelvis and ureteral spatulation without dismembering the UPJ. Both layers of ureteropelvic anastomosis are completed before dismemberment and pelvic reduction. Forty-one PAD procedures in 40 patients with UPJ obstruction and follow-up of at least 3 months were evaluated. Mean age was 37.2 years (range 2-82 years) with 22 patients younger than 15 years. The UPJ was dependent in 31 and had high insertion in 10 (24.4%). The stenotic segment was long (> or =1.5 cm) in 18 (43.9%). Crossing vessels and secondary calculi were observed in six (14.6%) and seven (17.1%) units. RESULTS Mean (+/- SD) blood loss, hospital stay, convalescence, and analgesia requirement were 68.1 +/- 37.6 mL, 3.8 +/- 1.1 days, 11.4 +/- 3.9 days, and 204.8 +/- 60.5 mg diclofenac, respectively. The mean operative time was 97.6 +/- 22.1 minutes. There was one intraoperative complication in the form of injury to a renal vein tributary, with no transfusions or conversions. Postoperative complications included pain after stent removal, persistent drainage, and pyelonephritis in 1, 2, and 4 patients, respectively. Mean follow-up was 19.5 months (range 3-58 months), with a success rate of 95.1%. Failures were not attributable to UPJ configuration, length of stenosis, or age. CONCLUSIONS The PAD technique has several practical advantages with a shorter operative time compared with other historical series of laparoscopic pyeloplasty (LP). It combines the ease of nondismembered LP with the excellent outcome of dismembered techniques.