Hasan A.R. Qazi

Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE Radical prostatectomy is the gold standard surgical treatment for organ-confined prostate cancer. There is no consensus on the impact of previous laparoscopic experience on the learning curve of robot-assisted laparoscopic prostatectomy (RALP). We compared the perioperative complications and early patient outcomes from our initial 100 cases of RALP with laparoscopic prostatectomy (LRP) cases performed well beyond the learning curve. PATIENTS AND METHODS Between July 2011 and January 2012, 110 RALP were performed by one of two surgeons, each with previous experience of more than 1000 LRP. The cases were pair matched from among the last 208 patients who had undergone LRP by the same surgeons at the same time. The clinical parameters, operative details, postoperative complications, and short-term outcomes from these patients, collected prospectively, were compared between the two groups. RESULTS The prostate-specific antigen (PSA) level and age of the two groups was similar. The operative time (128.4 vs 153.9 min; P=0.01) and blood loss (200 vs 254 mL; P=0.01) was significantly less for the LRP group, but the duration of catheterization was similar (5.89 vs 6.2 days). The complication rate was low. No procedures needed conversions, and no patient had a visceral injury or blood transfusion. Twenty-three patients in the LRP group and 33 patients in the RALP group had extraprostatic disease, and the positive margin rate was 14% and 19% for these respective groups. At 3 months, PSA level was undetectable in 94% of LRP and 92% RALP patients, while 56% and 65% (P=0.062) patients in these groups were using 0 to 2 pads per day. CONCLUSIONS The initial results of the outcome of RALP are at least at par with those of LRP and with those of previously published RALP series. This suggests the lack of a steep learning curve for experienced laparoscopic surgeons in performing RALP.

Shockwave Lithotripsy: Arterial Aneurysms and Vascular Complications

BACKGROUND AND PURPOSE The application of shockwave lithotripsy (SWL) in patients with arterial aneurysm remains controversial, and several case reports exist in the world literature that describe both safe use and rupture. In addition, other vascular complications have been reported. The potential for hemorrhage is affected by coagulation status and antiplatelet therapy, yet little evidence exists on their interaction with SWL. We aim to review the vascular complications after SWL. METHODS A review of the world literature was performed in accordance with methodology that is defined by the Cochrane Collaboration. An Internet bibliographic search on MEDLINE was performed during May and June 2010, with additional hand-searching of references. The search terms lithotripsy, aneurysm, abdominal aortic aneurysm, pseudoaneurysm, hemorrhage, hematoma, coagulation, aspirin, clopidogrel, and warfarin were used. RESULTS In reported cases, there have been 18 patients with abdominal aortic aneurysm (AAA) who have undergone SWL. Both safe and uncomplicated treatment have been reported as well as rupture of AAA. Other vascular complications after SWL have included pseudoaneurysm, venous thrombosis, arterial stenosis, and arteriovenous fistulation. Patients with hemorrhagic risk factors can undergo SWL after correction of coagulopathy. Experimental work on animal models and human tissue has evaluated the effects of SWL on the vasculature. CONCLUSION There is currently no high-level evidence to suggest that SWL in the presence of arterial aneurysm is unsafe. Experimental work on ex vivo human tissue does not suggest that SWL is causative to aneurysm rupture. With the availability of CT imaging in modern clinical practice, aneurysms of the arterial tree should be identified as part of the investigation of urinary tract calculi. SWL can be safely performed in patients with AAA, but monitoring postprocedure is mandatory, along with access to emergency vascular surgery support; importantly, any onset of new pain or symptoms should be aggressively investigated by radiologic imaging in the first instance.

Robot-assisted laparoscopic total extraperitoneal hernia repair during prostatectomy: technique and initial experience.

Introduction To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes. Material and methods 12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure. Results Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data. Conclusions Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

Nephrobronchial fistula - a case report.

We report the case of a 58-year-old woman with a hydronephrotic left kidney who presented with a 4-month history of anorexia, weight loss and intermittent left loin pain associated with cloudy urine. Her urine grew lactose fermenting coliforms, and was treated with antibiotics. A computerized axial tomography scan (CT scan) was equivocal and she underwent retrograde ureteric stenting, which drained a pyonephrosis. She went on to develop a chest infection due to a lung abscess. A CT scan revealed a left perinephric collection extending across the diaphragm into the lower lobe of the left lung. She responded to antibiotics and awaits a nephrectomy.

‘The Transylvania Effect’ – Does the Lunar Cycle Affect Emergency Urological Admissions?

Background: The influence of the full moon remains a common explanation for wide range of events from death to violence in psychiatric setting. Research has failed to show an association with psychiatric disorders, suicide and selfpoisoning or accidents. However, an increase in unintentional poisoning, absenteeism and aggression has been reported. Our study assessed whether the gravitational pull of the moon generated a tidal wave of increased emergency urological admissions. Patients and Methods: Data was obtained from the Hospital Centralised Emergency Database for a 2-year period of patients who presented as urological emergencies. We assessed daily patterns in emergency room attendees for age, sex, and disease against the lunar cycle and other weekdays. Results: Thirty-five hundred and fortyseven patients presented as urological emergencies (2,057 men, 1,490 women), overall mean of 4.96 patients per day. There were 68 peak days (>8 admissions/day). Emergency presentations peaked around mid-summer and New Year. Patterns were similar for both female and male attendees. Mean daily attendances peaked on Mondays and troughed on Wednesdays (5.1 ± 2.2 vs. 4.5 ± 2.3). Full moons (5.5 ± 2.3 d, p = 0.75) were associated with a higher urological emergencies compared to other days (4.9 ± 2.4 d) while new moons (5.1 ± 2.4 d, p = 0.89) seemed to calm the urological system. Conclusion: Emergency urological admissions were higher on full moon days. The new moon had a calming effect. These trends though not significant, show a possible influence of the lunar cycle on urological admissions. The debate on the lunar cycle effect on human health and behavior continues.