I. Kyriazis

Postoperative Lymphocele Formation after Pelvic Lymph Node Dissection at the Time of Radical Prostatectomy Should Not Be Considered an Inevitable Consequence of the Approach

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Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

DIFF] espite ongoing debate on the therapeutic value of PLND during RP, substantial morbidity associated with the procedure has been highlighted throughout the literature. Among other adverse effects, symptomatic lymphocele formation remains the predominant complication. Postoperative lymphoria and subsequent lymphocele formation of varying degree are expected in the vast majority of PLND cases; studies using regular radiologic investigation during follow-up report lymphocele formation in more than half of cases. The majority of such fluid collections are eventually absorbed uneventfully, and only a few cause symptoms, which can be either mild, such as voiding problems, or severe, such as deep vein thrombosis and/or fever (infected lymphocele) requiring intervention for management. Although a wealth of preventive strategies have been tested, urologists still face lymphocele as an inevitable consequence of PLND without being able to provide reliable measures to avoid it. In this issue of European Urology, Grande et al [1] report outcomes from a prospective randomized trial involving 231 patients in which titanium clips were compared to bipolar coagulation in sealing femoral canal lymphatic vessels during extended PLND at the time of robot-assisted RP. The trial could not show any difference in asymptomatic (47 vs 48%) and clinically significant lymphocele formation (5% vs 4%) between the two approaches. The authors conclude that sealing of lymphatic vessels is equally effective using titanium clips or bipolar coagulation, and question the value of metal clipping [1]. The authors should be congratulated for their work, drawing interest to a very common practice in pelvic oncologic surgery.

Percutaneous nephrolithotomy puncture and tract dilation: Evidence on the safety of approaches to the infundibulum of the calyx

Abstract Objectives: To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP). Methods: The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be ≥6 months. Results: In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of −0.30 days (95% confidence interval [CI] −0.35, −0.24) for the laparoscopic group and 1.09 days (95% CI −1.47, −0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01). Conclusion: This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate.

Stone retropulsion with Ho:YAG and Tm:YAG lasers: A clinical practice oriented experimental study

Objective To investigate the anatomical relations of the papillary, infundibular, and pelvic approach to percutaneous nephrolithotomy and evaluate the amount of vascularization at the respective sites. Materials and Methods 99m Tc-dimercaptosuccinic acid single-photon emission computed tomography/computed tomography (SPECT/CT) renal scintigraphies or computed tomography perfusion (CTP) was performed in 40 patients (prone n = 20 or supine position n = 20). The angle of approach (AoA) for access tracts and the respective regions of interest to the mid-calyceal papilla and infundibulum as well as renal pelvis were designed and compared. Results The design of access tracts aiming to the renal pelvis, papilla, and infundibulum of the renal calyx was impossible for the nondilated collecting systems as all these tracts were in close vicinity. In both SPECT/CT and CTP, there was no statistical difference between the AoA for infundibular or pelvic access in comparison with the papillary puncture in either prone or supine position regardless of the degree of dilation of the system. The comparison of the measurements in the regions of interest showed that there was no difference in blood supply between the infundibular and pelvic access in comparison with the papillary approach in both positions regardless of the degree of collecting system dilation. Conclusion The use of SPECT/CT and CTP showed that the punctures to the mid-calyceal renal papilla-fornix and infundibulum as well as the renal pelvis at the same level have similar AoA. The sites of the parenchyma involved in the tract dilation of the respective approaches are not related to significant differences in terms of vascularization.

Re: Comparison of Perioperative Outcomes Between Robotic and Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-analysis

OBJECTIVE To compare the retropulsion of stones with the use of holmium: yttrium aluminum garnet (Ho: YAG) laser and thulium: yttrium aluminum garnet (Tm: YAG) laser in settings that could be used in clinical practice. METHODS The experimental configuration included a glass tube set in a water bath filled with physiologic saline. Plaster of Paris stones were inserted in the tube. Tm: YAG and Ho: YAG laser systems were used along with a high-speed slow-motion camera. The lasers were activated with different settings. The displacement of the stone was measured according to a custom-made algorithm. RESULTS Ho: YAG: the retropulsion of stones was the lowest with the energy setting of 0.5 J and the frequency of 20 Hz with long pulse duration. The highest retropulsion was observed in the case of 3 J, 5 Hz, and short pulse. Tm: YAG: the retropulsion of stones was the lowest with the energy setting of 1 J and the frequency of 10 Hz with either long or short pulse duration. Practically, there was no retropulsion at all. The highest retropulsion was observed in the case of 8 J, 5 Hz, and short pulse. CONCLUSION Ho: YAG laser has a linear increase in stone retropulsion with increased pulse energy. On the other hand, the retropulsion rate was kept to the minimum with Tm: YAG as much as the energy level of 8 J. The activation of lasers with short pulse resulted in further displacement of the stone. Lower frequency with the same power setting seemed to result in further stone retropulsion. Higher power with the same frequency setting resulted in further displacement of the stone.

25 Magnetic tracking technology used to compare ergonomics of single site and conventional laparoscopic surgery: Preliminary results

[1] Li W-Q, Qureshi AA, Ma J, et al. Personal history of prostate cancer and increased risk of incident melanoma in the United States. J Clin Oncol 2013;31:4394–9. [2] Loeb S, Folkvaljon Y, Lambe M, et al. Use of phosphodiesterase type 5 inhibitors for erectile dysfunction and risk of malignant melanoma. JAMA 2015;313:2449–55. [3] Hill AB. The environment and disease: Association or causation? Proc Royal Soc Med 1956;58:295–300.

255 Parstatin attenuates renal ischemia reperfusion injury in rats

INTRODUCTION AND OBJECTIVES: Minimal invasive urologic surgery may benefit from ergonomic motion analysis, as the surgeonAEs joints are often in non-optimal positions, leading to premature fatigue. We propse to examine and compare the ergonomics of simulated single-site surgery and conventional laparoscopic surgery. METHODS: A laparoscopic box trainer is used to simulate surgical conditions. To simulate conventional laparoscopic surgery, two instruments are inserted bilaterally and the camera in the center position. Single site surgery is simulated by inserting an Endocone (Karl Storz, Germany) in the center position and inserting a double bent grasper, a straight grasper and the camera through it. Standard laparoscopic training tasks (object transfer, knot tying) are performed and ergonomic data is captured. Magnetic tracking technology is used to obtain position and orientation data for the operatorAEs wrists, elbows and shoulders at a rate of thirty times per second. The data is inserted into an algorithm which calculates the ergonomic scores for each posture throughout the execution of the laparoscopic task. At the end, the algorithm can compare the ergonomic performance of different laparoscopic methods using the analyzed scores. The analysis is based on the RULA method (Rapid Upper Limb Assessment). RESULTS: Preliminary analysis of the data show that joints are in non-optimal positions in single site surgery, as compared to conventional laparoscopic surgery. This is demonstrated by the higher arm and wrist RULA scores obtained for tasks conducted through the single port systems (Test 10) in comparison to tasks conducted through a conventional laparoscopic setup (Test 1). CONCLUSIONS: Ergonomic motion analysis may yield results that lead to the improvement of minimal invasive surgical techniques and equipment.

National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany

INTRODUCTION AND OBJECTIVES: Parstatin, is a 41 amino acid peptide that is cleaved from the proteinase-activated receptor-1 (PAR-1) during its activation by thrombin. Previous studies have demonstrated that parstatin as well as its hydrophobic N-terminal part (parstatin 1–26) demonstrate cardioprotective properties in in-vivo and in vitro experimental models of cardiovascular ischemia reperfusion injury. In this study we examine whether parstatin as well as parstatin 1–26 attenuates renal ischemia reperfusion injury (RIRI) in a rat model. METHODS: In total 106 male Wistar rats were used for the purposes of this study. RIRI model included 45 minutes of bilateral renal ischemia, though clamping of both renal pedicles, followed by 4 hours of reperfusion. The effects of Parstatin on RIRI were initially examined in 77 animals divided into 8 groups including sham (vehicle/no ischemia), sham/parstatin (parstatin/no ischemia), control (vehicle pretreatment/ischemia), parstatin 3–100ig/Kg (pretreatment with 3, 10, 30 or 100ig/Kg parstatin/ischemia), scramble (pretreatment with a non-parstatin 41 aminoacid peptide/ischemia) and after (ischemia/ administration of 30ig/Kg parstatin after ischemia). The effects of parstatin 1–26 were then examined in 29 animals divided into 5 groups, including control (vehicle/ischemia), parstatin 1–26 1–100 ig/Kg (pretreatment with 1, 10 or 100ig/Kg parstatin 1–26/ischemia) and after (ischemia/administration of 10ig/Kg parstatin 1–26 after ischemia). At the end of reperfusion period all animals were sacrificed and their kidneys, urine and blood samples were taken for histological and biochemical examination. Studied parameters were serum creatinine and BUN levels, Fractional Excretion of Sodium (FENa) and histological evaluation of renal specimens. RESULTS: Administration of 10 or 30ig/Kg of parstatin before or 30ig/Kg after renal ischemia attenuated RIRI. Dose response study revealed that at the higher examined dose (100ig/Kg parstatin effects were reversed. Pretreatment with 10ig/Kg of parstatin 1–26 attenuated RIRI as well. Nevertheless, parstatin 1–26 failed to induce statistically significant nephroprotection when administered after ischemia. CONCLUSIONS: Parstatin as well its hydrophobic N-terminal segment, parstatin 1–26, can preserve renal function and histological status in RIRI. The latter reveals a potential role of this molecule in clinical entities related to the phenomenon of RIRI such as partial nephrectomy.