George L. Martin

Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: Seven-year experience

PURPOSE We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava. PATIENTS AND METHODS A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. RESULTS Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. CONCLUSION In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.

Comparison of total, selective, and nonarterial clamping techniques during laparoscopic and robot-assisted partial nephrectomy

PURPOSE This study evaluates the feasibility, perioperative, and renal functional outcomes with total, selective, and nonarterial clamping techniques during minimally invasive partial nephrectomy. METHODS A retrospective review of laparoscopic and robot-assisted partial nephrectomies by a single surgeon from January 2007 to July 2010 was performed. Patients underwent total hilar clamping, selective (segmental) artery clamping, progressive clamping from segmental to main renal artery clamping, or resection without hilar clamping. Patient demographic, perioperative, and oncologic outcomes were analyzed. Change in renal function was assessed by glomerular filtration rate (GFR) calculation and differential function on pre- and postoperative renal scans. RESULTS A total of 68 patients underwent laparoscopic or robot-assisted partial nephrectomy. Those with a history of surgery for renal masses and elective conversion to radical nephrectomy were excluded. A total of 57 patients were analyzed (32 total hilar, 8 progressive arterial clamping, 13 selective arterial, and 4 without clamping). There were no significant differences in preoperative patient or disease characteristics between the groups. The progressive clamping technique was found to significantly decrease the total renal ischemia time compared with the total hilar clamp technique. There was no other significant difference in transfusion rate, complications, or other postoperative outcomes. There were no significant differences between the groups in intermediate-term (mean 411 days) renal function changes. CONCLUSIONS Minimally invasive partial nephrectomy without vascular occlusion and with selective arterial clamping is feasible and can be safely performed. With this intermediate-term follow-up there was no clinically significant benefit seen for selective regional or nonischemic techniques.

Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes.

To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot‐assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection.

Outpatient Prostatectomy: Too Much Too Soon or Just What the Patient Ordered

OBJECTIVES To evaluate the feasibility of performing a robot-assisted radical prostatectomy (RARP) as an outpatient procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for outpatient RARP. METHODS We performed a prospective study with 11 patients undergoing extraperitoneal RARP. These patients were counseled before the procedure that they would go home the same evening of the procedure. The patients were then surveyed by a third party shortly after they returned home, using the Patient Judgement System-24, a previously validated instrument for patient satisfaction. Sociodemographic data, comorbidities, and outcomes were collected for analysis. RESULTS All patients were successfully discharged the same day of surgery. Mean patient age was 62.2 years with a mean body mass index of 26 kg/m(2). Mean operative time was 117.6 minutes, console time was 76.7 minutes, and estimated blood loss was 168.2 mL. Mean indwelling catheter time was 7.5 days. No complications occurred in this series of patients. Satisfaction was unanimously high in all patients surveyed, with most scores over 90% on the Patient Judgement System-24. No patient reported any ill effects from the shortened stay or felt rushed to leave the hospital. CONCLUSIONS The early experience with extraperitoneal RARP as a same day surgery is promising. Preoperative patient counseling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, assessment of intraoperative findings, and adequate postoperative assessment are essential.

Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation.

Study Type – Therapy (case series)

Does a history of previous surgery or radiation to the prostate affect outcomes of robot―assisted radical prostatectomy?

To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot‐assisted radical prostatectomy (RARP) after the initial ‘learning curve’, as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate.

Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects

PURPOSE To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in subjects who have had no previous laparoscopic experience. MATERIALS AND METHODS Twenty-nine medical students were given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group subjects were advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared. RESULTS Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. The facility group did objectively better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 vs 2.4 point average increase, P=0.03). CONCLUSIONS Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is comparable to the standard trainer for improvement of basic laparoscopic skills.

Salvage Robot-Assisted Radical Prostatectomy (SRARP)

Surgical management of radiorecurrent prostate cancer remains a challenge for urologic surgeons regardless of surgical approach (open or robotic). The surgical standard has always been salvage open radical prostatectomy via a retropubic or perineal approach. With the advent of robotics, surgeons now have a new surgical approach to offer patients suffering from the difficult diagnosis of radiorecurrent prostate cancer. Herein, we aim to review the current literature on biochemical recurrence of prostate cancer following primary treatment with radiation and the role of surgical treatment (open, laparoscopic, and robotic). Indications, patient selection, preoperative preparation, and technical modifications for salvage robot-assisted radical prostatectomy (SRARP) will be reviewed in this chapter.

History of Cystoprostatectomy and Ileal Conduit with Development of Recurrent, Massive Hemorrhage from Peristomal Varices

Bleeding from ileal conduit peristomal varices is an uncommon complication of hepatic cirrhosis. Treatment with local measures such as compression and suture ligation is associated with high recurrence rates and does not address the underlying pathology. Herein we describe two similar cases of bleeding peristomal varices managed differently due to unique patient characteristics. One was treated with transjugular intrahepatic portosystemic shunt and the other with direct percutaneous access of the varix with coil embolization.