Luis Medina

Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery

BACKGROUND The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.

Single port radical prostatectomy: current status

The aim of this study is to analyze the current literature on single port radical prostatectomy (LESS-RP). Single port radical prostatectomy laparoendoscopic (LESS-RP) has established itself as a challenge for urological community, starting with the proposal of different approaches: extraperitoneal, transperitoneal and transvesical, initially described for laparoscopy and then laparoscopy robot-assisted. In order to improve the LESS-RP, new instruments, optical devices, trocars and retraction mechanisms have been developed. Advantages and disadvantages of LESS-RP are controversial, while some claim that it is a non-trustable approach, regarding the low cases number and technical difficulties, others acclaim that despite this facts some advantages have been shown and that previous described difficulties are being overcome, proving this is novel proposal of robotics platform, the Da Vinci SP, integrating the system into “Y”. The LESS-RP approach gives us a new horizon and opens the door for rapid standardization of this technique. The few studies and short series available can be result of a low interest in the application of LESS-RP in prostate, probably because of the technical complexity that it requires. The new robotic platform, the da Vinci SP, shows that it is clear that the long awaited evolution of robotic technologies for laparoscopy has begun, and we must not lose this momentum.

Impact of Surgical Factors on Robotic Partial Nephrectomy Outcomes: Comprehensive Systematic Review and Meta-analysis

Purpose: Utilization of robotic partial nephrectomy has increased significantly. We report a literature wide systematic review and cumulative meta‐analysis to critically evaluate the impact of surgical factors on the operative, perioperative, functional, oncologic and survival outcomes in patients undergoing robotic partial nephrectomy. Materials and Methods: All English language publications on robotic partial nephrectomy comparing various surgical approaches were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta‐Analyses) statement and AHRQ (Agency for Healthcare Research and Quality) guidelines to evaluate PubMed®, Scopus® and Web of Science™ databases (January 1, 2000 to October 31, 2016, updated June 2017). Weighted mean difference and odds ratio were used to compare continuous and dichotomous variables, respectively. Sensitivity analyses were performed as needed. To condense the sheer volume of analyses, for the first time data are presented using novel summary forest plots. The study was registered at PROSPERO (https://www.crd.york.ac.uk/prospero/, ID CRD42017062712). Results: Our meta‐analysis included 20,282 patients. When open partial nephrectomy was compared to robotic partial nephrectomy, the latter was superior for blood loss (weighted mean difference 85.01, p <0.00001), transfusions (OR 1.81, p <0.001), complications (OR 1.87, p <0.00001), hospital stay (weighted mean difference 2.26, p = 0.001), readmissions (OR 2.58, p = 0.005), percentage reduction of latest estimated glomerular filtration rate (weighted mean difference 0.37, p = 0.04), overall mortality (OR 4.45, p <0.0001) and recurrence rate (OR 5.14, p <0.00001). Sensitivity analyses adjusting for baseline disparities revealed similar findings. When robotic partial nephrectomy was compared to laparoscopic partial nephrectomy, the former was superior for ischemia time (weighted mean difference 4.21, p <0.0001), conversion rate (OR 2.61, p = 0.002), intraoperative (OR 2.05, p >0.0001) and postoperative complications (OR 1.27, p = 0.0003), positive margins (OR 2.01, p <0.0001), percentage decrease of latest estimated glomerular filtration rate (weighted mean difference ‐1.97, p = 0.02) and overall mortality (OR 2.98, p = 0.04). Hilar control techniques, selective and unclamped, are effective alternatives to clamped robotic partial nephrectomy. An important limitation is the overall suboptimal level of evidence of publications in the field of robotic partial nephrectomy. No level I prospective randomized data are available. Oxford level of evidence was level II, III and IV in 5%, 74% and 21% of publications, respectively. No study has indexed functional outcomes against volume of parenchyma preserved. Conclusions: Based on the contemporary literature, our comprehensive meta‐analysis indicates that robotic partial nephrectomy delivers mostly superior, and at a minimum equivalent, outcomes compared to open and laparoscopic partial nephrectomy. Robotics has now matured into an excellent approach for performing partial nephrectomy for renal masses.

Complications of Robotic Surgical Access

The Latin term for fistula is “pipe” or “tube” and means an extra-anatomic anastomosis between two hollow organs (or an hollow organ and the environment). A fistula between the lower urinary tract and the vagina is termed vesicovaginal (VVF) or vesicourethral fistula; in high income countries, both fistula are almost exclusively iatrogenic, but may also result from, malignancy, inflammation or appear as congenital fistula.

Needle lost in minimally invasive surgery: management proposal and literature review

The reported incidence of intraoperative retained instruments, such as needles, hangs around 0.06–0.11%. Leaving a needle inside the abdominal cavity can have significant medical and legal consequences. In addition, the retrieval can be hampered due to the limited visualization of the scope during minimally invasive surgery. Factors associated with an increased probability for NL have been described. Prevention for this situation includes: having one needle at a time inside the cavity, effective communication between all personnel in the operating room, evaluation of the strength of the suture–needle connection, avoid parking of needles intraoperatively, and a proper needle withdrawal. Notwithstanding, no agreement has been made regarding NL management. Herein, we present a literature review, and a management proposal in which through a series of systematic steps, the surgical team can efficiently locate and retrieve a lost needle such as: examination of the surgical field, trocar visualization, trocar disassembly, and revision of the suction device. Finally, intraoperative or postoperative imaging can be utilized.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann’s reversal procedure

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

Impact of Renal Hilar Control on Outcomes of Robotic Partial Nephrectomy: Systematic Review and Cumulative Meta-analysis

CONTEXT During robotic partial nephrectomy (RPN), various techniques of hilar control have been described, including on-clamp, early unclamping, selective/super-selective clamping, and completely-unclamped RPN. OBJECTIVE To evaluate the impact of various hilar control techniques on perioperative, functional, and oncological outcomes of RPN for tumors. EVIDENCE ACQUISITION We conducted a systematic literature review and meta-analysis of all comparative studies on various hilar control techniques during RPN using PubMed, Scopus, and Web of Science according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement, and Methods and Guide for Effectiveness and Comparative Effectiveness Review of the Agency for Healthcare Research and Quality. Cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3. EVIDENCE SYNTHESIS Of 987 RPN publications in the literature, 19 qualified for this analysis. Comparison of off-clamp versus on-clamp RPN (n=9), selective clamping versus on-clamp RPN (n=3), super selective clamping versus on-clamp RPN (n=5), and early unclamped versus on-clamp (n=3) were reported. Patients undergoing RPN using off-clamp, selective/super selective, or early unclamp techniques had higher estimated blood loss compared with on-clamp RPN (weight mean difference [WMD]: 47.83, p=0.000, WMD: 41.06, p=0.02, and WMD: 37.50, p=0.47); however, this did not seem clinically relevant, since transfusion rates were similar (odds ratio [OR]: 0.98, p=0.95, OR: 0.72, p=0.7, and OR: 1.36, p=0.33, respectively). All groups appeared similar with regards to hospital stay, transfusions, overall and major complications, and positive cancer margin rates. Short- and long-term renal functional outcomes appeared superior in the off-clamp and super selective clamp groups compared with the on-clamp RPN cohort. CONCLUSIONS Off-clamp, selective/super selective clamp, and early unclamp hilar control techniques are safe and feasible approaches for RPN surgery, with similar perioperative and oncological outcomes compared with on-clamp RPN. Minimizing global renal ischemia may provide superior renal function preservation. However, higher quality data are necessary for definitive conclusions in this regard. PATIENT SUMMARY The objective of partial nephrectomy is to treat the cancer while maximizing renal function preservation. Clamping the main vessels is done primarily to reduce the blood loss during partial nephrectomy; however, vascular clamping can compromise kidney function. In order to avoid clamping, various techniques have been described. Our analysis showed that techniques that avoid main renal artery clamping during RPN are associated with better renal function preservation, yet deliver non-inferior perioperative and oncological outcomes as compared with RPN procedures that clamp the main vessels.

Transvesical robot-assisted simple prostatectomy with 360° circumferential reconstruction: step-by-step technique

To present the step‐by‐step technique of a 360° mucosal reconstruction after transvesical robot‐assisted simple prostatectomy (RASP).

Impact of Preoperative Patient Characteristics and Flow Rate on Failure, Early Complications, and Voiding Dysfunction After a Transobturator Tape Procedure: A Multicentre Study

Purpose To evaluate the impact of preoperative patient characteristics and flow rate on failure, early postoperative complications, and voiding in patients who underwent transvaginal tension-free vaginal tape-obturator (TVT-O) treatment for uncomplicated stress urinary incontinence (SUI). Methods We retrospectively reviewed patients who underwent TVT-O for SUI at 3 Italian centres. The exclusion criteria were predominant voiding and storage symptoms suggestive of detrusor overactivity, the presence of grade >1 urogenital prolapse, previous pelvic radiotherapy or other clinical contraindications for surgical procedures, neurogenic bladder dysfunction, and collagen diseases. Multivariate logistic regression models were constructed to identify predictors of early voiding dysfunction after TVT-O. Results A total of 219 patients underwent TVT-O between January 2010 and December 2015. All patients received follow-up at 3, 6, and 12 months, and underwent a stress test, uroflowmetry, and bladder ultrasound to evaluate the postvoid residual volume. They also responded to the Urogenital Distress Inventory (UDI-6) questionnaire. The rates of persistent incontinence after TVT-O, postoperative complications, and satisfaction were 16.4% (36 of 219), 24.2% (53 of 219), and 86.3% (189 of 219), respectively. Nineteen patients (9.5%) experienced early voiding dysfunction. Based on an analysis of baseline characteristics, we determined that a cutoff value of 9.0 on the UDI-6 predicted postoperative SUI with 62% specificity, 72% sensitivity, and 66% accuracy. In the multivariate logistic regression analysis, a preoperative UDI-6≥9.0 was an independent predictor of postoperative SUI. The predictors of complications were menopause (P = 0.04) and the preoperative UDI-6 score (P = 0.01). Conclusions Menopause and UDI-6 scores could be prognostic factors for persistent SUI after TVT-O. Well-designed prospective studies with a suitable number of patients are needed to corroborate our findings.

Primary non-Hodgkin lymphoma of the prostate: a case report

This report is of a 68-year-old male patient with a three-year history of severe, progressive, low urinary tract symptoms (LUTS) with a score of 20 points on the International Symptom Scale. The patient received alpha-1-blocker therapy without adequate response. Transurethral resection of the prostate was performed, and the anatomopathological report indicated the presence of a haematolymphoid small-cell neoplasia and glandulostromal prostatic hyperplasia. Posterior immunohistochemistry evaluation reported an extra-nodal marginal zone-B lymphoma non-Hodgkin lymphoma. The patient was followed up for five years by the urology and oncology departments. In the fourth year of follow-up, the patient had B symptoms (fever, night sweats and weight loss). At the same time, laboratory tests showed haemolytic anaemia; then a new bone marrow biopsy was carried out. The histopathological specimen showed six lymphoid aggregates, constituted by a B-cell population with intra-trabecular predominance and reactivity for CD20 and BCL-2. New thoracic and abdominal computed tomographies were performed without any findings suggestive of extra-prostatic spreading. Subsequently, a chemotherapy regimen was started on the patient with the following therapeutic scheme: Rituximab 375 mg/m2 IV per day, cyclophosphamide 750 mg/m2 IV per day, Vincristine 1.4 mg/m2 IV dose per day and Prednisone 40 mg/m2 on days 1–5 (R-CVP scheme) for 21 days, until he completed six cycles. No signs, symptoms or progression have been recorded.