Hubert John

Surgery-related Complications of Robot-assisted Radical Cystectomy With Intracorporeal Urinary Diversion

OBJECTIVESnTo assess the surgery-related complications at robot-assisted radical cystectomy with total intracorporeal urinary diversion during our learning curve in treating 45 patients with bladder cancer.nnnMETHODSnA total of 45 patients were pooled in 3 consecutive groups of 15 cases each to evaluate the complications according to the Clavien classification. As a surrogate for our learning curve, the following parameters were assessed: operative time, blood loss, urinary diversion type, lymph node yield, surgical margin status, and length of hospital stay.nnnRESULTSnEarly surgery-related complications were noted in 40% of the patients and late complications in 30%. The early Clavien grade III complications remained significant (27%) and did not decline with time. Overall, fewer complications were observed between the groups over time, with a significant decrease in late versus early complications (P = .005 and P = .058). The mean operative times declined from the first group to the second and third groups (P = .005) and the hospital stays shortened (P = .006). No significant difference was observed between groups regarding the lymph node yield at cystectomy (P = .108), with a mean of 22.5 nodes (range 10-52) removed. More patients received an orthotopic bladder substitute (Studer) in each of the latter 2 groups than in the first.nnnCONCLUSIONSnAlthough robot-assisted radical cystectomy with total intracorporeal urinary diversion is a complex procedure, we observed decreased surgery-related complications and improved outcomes over time in the present series. Our results need to be confirmed by others before robot-assisted radical cystectomy with totally intracorporeal urinary diversion can be accepted as a treatment option for patients with bladder cancer.

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.

Benign atypical intravascular CD30+ T-cell proliferation: a recently described reactive lymphoproliferative process and simulator of intravascular lymphoma: report of a case associated with lichen sclerosus and review of the literature.

OBJECTIVESnIntravascular accumulations of atypical large lymphoid cells are a rare finding in skin biopsy specimens and raise the suspicion for intravascular lymphoma. The intravascular accumulation of atypical large CD30+ T cells, however, as a reactive process is very uncommon in the skin, with only four cases documented so far in the literature. This condition, referred to as benign intravascular atypical CD30+ T-cell proliferation, has been associated with chronic inflammation after trauma.nnnMETHODSnWe report on a case of atypical intravascular CD30+ T-cell proliferation in a patient with ulcerated lichen sclerosus on the foreskin, discuss the differential diagnoses, propose diagnostic criteria, and review the literature on this uncommon reactive intralymphatic CD30+ T-cell lymphoproliferation.nnnRESULTSnThe atypical intravascular CD30+ T-cell proliferation is characterized by the accumulation of large CD30+ polyclonal T cells within lymphatics in close vicinity to ulceration or an inflammatory skin disease. There is no association with Epstein-Barr virus infection.nnnCONCLUSIONSnThis benign cutaneous lymphoproliferation needs to be distinguished from intravascular T-cell lymphoma, particularly from the intravascular variant of anaplastic large cell lymphoma. Obstruction of lymphatics due to lichen sclerosus with disrupted immune cell trafficking may result in the accumulation of activated CD30+ lymphocytes.

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

OBJECTIVESnTo compare pre- and postoperative urodynamic findings in patients with a bulbourethral composite suspension and intraoperative urodynamically controlled sling tension adjustment.nnnMETHODS AND PATIENTSnAll 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.nnnRESULTSnSling 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.nnnCONCLUSIONSnAccording 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 65u2003kg/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.

Da Vinci© Skills Simulator™: is an early selection of talented console surgeons possible?

To investigate whether the learning curve of robotic surgery simulator training depends on the probands’ characteristics, such as age and prior experience, we conducted a study of six distinct proband groups, using the da Vinci Skills Simulator: experienced urological robotic surgeons, surgeons with experience as da Vinci tableside assistants, urological surgeons with laparoscopic experience, urological surgeons without laparoscopic experience, and complete novices aged 25 and younger and 40 and older. The results showed that all experienced robotic surgeons reached expert level (>90xa0%, as defined previously in the literature) within the first three repetitions and remained on a high level of performance. All other groups performed worse. Tableside assistants, laparoscopically experienced surgeons, and younger novices showed a better performance in all exercises than surgeons without laparoscopic experience and older novices. A linear mixed-effects model analysis demonstrated no significant difference in learning curves between proband groups in all exercises except the RW1 exercise for the younger proband group. In summary, we found that performance in robotic surgery, measured by performance scores in three virtual simulator modules using the EndoWrist techniques, was dependent on age and prior experience with robotic and laparoscopic surgery. However, and most importantly, the learning curve was not significantly affected by these factors. This suggests that the da Vinci Skills Simulator™ is a useful practice tool for everyone learning or performing robotic surgery, and that early selection of talented surgeons is neither possible nor necessary.

ESUT expert group on laparoscopy proposes uniform terminology during radical prostatectomy: We need to speak the same language

Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Germany; Department of Urology, AMC Amsterdam, University of Amsterdam, The Netherlands; Department of Urology, Centre of Oncology, Kielce, Poland; Department of Urology, Pansadoro Foundation, Rome, Italy; Department of Urology, Luigi Sacco Hospital, University of Milan, Italy; Department of Urology, Medical School Leipzig, University of Leipzig, Germany; Department of Urology, Institute Montsouris, Paris, France; Department of Urology, University of Patras, Greece; Department of Urology, Gazi University of Ankara, Turkey; Department of Urology, Helios Kliniken Mullheim, Germany; Department of Urology, Klinikum Winterthur, Switzerland; Department of Urology, University of Basel, Switzerland; Department of Urology, Institute Jules Bordet – Universite Libre de Bruxelles, Brussels, Belgium

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

INTRODUCTIONnPenile constriction rings are either used for autoerotic stimulus or to increase sexual performance. Potentially, they can become irremovable and cause urologic emergencies.nnnAIMnWe describe the successful removal of a 3.6-cm long piece of heavy metal tubing used as a penile constriction ring.nnnMETHODSnAn 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.nnnRESULTSnAfter 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.nnnCONCLUSIONnDepending 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.

Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis

Importance Studies investigating the association of cigarette smoking with prostate cancer incidence and outcomes have revealed controversial results. Objective To systematically review and analyze the association of smoking status with biochemical recurrence, metastasis, and cancer-specific mortality among patients with localized prostate cancer undergoing primary radical prostatectomy or radiotherapy. Data Sources A systematic search of original articles published between January 2000 and March 2017 was performed using PubMed, MEDLINE, Embase, and Cochrane Library databases in March 2017. Study Selection Observational studies reporting Cox proportional hazards regression or logistic regression analyses were independently screened. Data Extraction and Synthesis This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Available multivariable hazard ratios (HRs) and corresponding 95% CIs were included in quantitative analysis. A risk-of-bias assessment was completed for nonrandomized studies. Main Outcomes and Measures Prespecified outcomes of interest were biochemical recurrence, metastasis, and cancer-specific mortality. Results A total of 5157 reports were identified, of which 16 articles were selected for qualitative analysis and 11 articles were selected for quantitative analysis. All included studies were observational and nonrandomized and comprised a total of 22 549 patients. Overall, 4202 patients (18.6%) were current smokers. The overall median follow-up was 72 months. Current smokers had a statistically significantly higher risk of biochemical recurrence (HR, 1.40; 95% CI, 1.18-1.66; Pu2009<u2009.001 [10 studies]), as did former smokers (HR, 1.19; 95% CI, 1.09-1.30; Pu2009<u2009.001 [7 studies]). Current smokers were also at a higher risk of metastasis (HR, 2.51; 95% CI, 1.80-3.51; Pu2009<u2009.001 [3 studies]) and cancer-specific mortality (HR, 1.89; 95% CI, 1.37-2.60; Pu2009<u2009.001 [5 studies]), whereas former smokers were not (metastasis: HR, 1.61; 95% CI, 0.65-3.97; Pu2009=u2009.31 [2 studies]; cancer-specific mortality: HR, 1.05; 95% CI, 0.81-1.37; Pu2009=u2009.70 [4 studies]). Conclusions and Relevance Current smokers at the time of primary curative treatment for localized prostate cancer are at higher risk of experiencing biochemical recurrence, metastasis, and cancer-specific mortality.

Internal Hernia Underneath an Elongated External Iliac Artery: A Complication After Extended Pelvic Lymphadenectomy and Robotic-assisted Laparoscopic Prostatectomy

Small bowel herniation underneath the iliac vessel after transperitoneal pelvic lymphadenectomy is a rare complication. This report describes the first case of bowel incarceration behind the external iliac artery after transperitoneal robotic-assisted radical prostatectomy with extended lymph node dissection in a patient with prostate cancer 1 year after surgery. After diagnosis on CT scan, an open resection of the ischemic bowel was performed. Because of thrombosis, the external iliac artery was opened, the clot was removed and the elongated artery was resected with end-to-end anastomosis. In case of a meandering iliac artery, a retroperitonealization after pelvic lymphadenectomy might be discussed.