M. Sangalli

Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours

BACKGROUND Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses. OBJECTIVE To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN. DESIGN, SETTING, AND PARTICIPANTS We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience. INTERVENTIONS The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma. MEASUREMENTS Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied. RESULTS AND LIMITATIONS The mean pathologic tumour size was 2.8 +/-1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 +/-33 min (range: 52-180), with a mean WIT of 20 +/- 7 min (range: 9-40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p<0.001) and 20 cases (p<0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 +/- 0.38 mg/dl to 1.1 +/- 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 +/- 29 to 80.5 +/- 29 (millilitres per minute per 1.73 m(2)) 3 mo postoperatively. CONCLUSIONS RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT < 20 min, console times < 100 min, limited blood loss, and acceptable overall complication rates.

Feasibility and Preliminary Clinical Outcomes of Robotic Laparoendoscopic Single-Site (R-LESS) Pyeloplasty Using a New Single-Port Platform

This study tested the technical feasibility and short-term perioperative outcomes of the novel da Vinci Single-Site Instrumentation platform for the treatment of upper ureteropelvic junction obstruction (UPJO) in a selected group of patients. Nine patients underwent robotic laparoendoscopic single-site (R-LESS) pyeloplasty using a new single-site platform for UPJO at our department of urology. All the procedures were completed without the need for traditional robotic surgery or laparoscopic/open conversion, although in one patient with congenital hepatomegaly it was necessary to use an auxiliary 3-mm trocar to retract the liver properly and expose the surgical field. Mean operative time was 166 min, and no intraoperative complications were recorded. The indwelling catheter was removed on postoperative day 2 in five patients and on postoperative day 3 in four patients. Patients were discharged the day after drain removal. One patient experienced transient hyperpyrexia, treated with antibiotics. No other complications were observed. All patients had the DJ stent removed 4 wk after surgery, following a negative urine culture and abdominal ultrasound evaluation. The five patients who reached a 3-mo follow-up had a clinical resolution of preoperative symptoms and hydronephrosis at the abdominal ultrasound. The same results were maintained in the two patients with 6-mo follow-up evaluations. In selected patients, R-LESS pyeloplasty using the new single-port platform appears to be a technically feasible and reproducible surgical procedure for the minimally invasive treatment of UPJO. Prolonged follow-up and larger series are required to confirm its potential role as a valid alternative to standard robotic pyeloplasty.

Initial Extended Transrectal Prostate Biopsy—Are More Prostate Cancers Detected With 18 Cores Than With 12 Cores?

PURPOSE We retrospectively investigated the detection rates of prostate cancer, high grade prostatic intraepithelial neoplasia and atypical glands suggestive of carcinoma by initial 18 and 12-core prostate biopsy. MATERIALS AND METHODS A total of 3,460 consecutive patients with prostate specific antigen between 2.5 and 15 ng/ml underwent 12 (1,684) or 18 (1,776) core prostate biopsy under local anesthesia at 2 departments that adopted the same indications for performing biopsy. Biopsies were evenly distributed throughout the prostate in 6 sectors. In the 12-core prostate biopsy group 2 samples were obtained from each sector and in the 18-core prostate biopsy group 1 additional core was taken from each sector. RESULTS The cancer detection rate in patients who underwent 18-core prostate biopsy was not different from the rate in those who underwent 12-core prostate biopsy (39.9% and 38.4%, p = 0.37), nor did the detection of atypical glands suggestive of carcinoma differ significantly between the 2 groups (2.9% and 3.3%, respectively, p = 0.33). However, 18-core prostate biopsy detected a significantly higher percent of cases of high grade prostatic intraepithelial neoplasia (20.0% vs 12.9%, p = 0.001). The cancer detection rate was higher with 18 than with 12-core prostate biopsy in patients with a prostate volume of 55 cc or greater (31.5% vs 24.8%, p = 0.01) but not in those with a prostate volume of less than 55 cc (54.3% and 53.0%, respectively, p = 0.7). Moreover, we determined that patients with positive digital rectal examination findings do not need 18-core prostate biopsy as opposed to 12-core prostate biopsy. CONCLUSIONS Compared with 12-core prostate biopsy, 18-core prostate biopsy detects significantly more cases of high grade prostatic intraepithelial neoplasia. However, 18-core prostate biopsy detects a significantly higher number of cancer only in patients with a prostate volume of 55 cc or greater.

Retroperitoneal and Transperitoneal Robot-Assisted Pyeloplasty in Adults: Techniques and Results

BACKGROUND The surgical management of ureteropelvic junction obstruction (UPJO) has dramatically evolved over the past 20 yr due to the development of new technology. OBJECTIVE Our aim was to report the feasibility and efficacy of robot-assisted pyeloplasty (RAP) performed by either the retroperitoneal or the transperitoneal approach. DESIGN, SETTING, AND PARTICIPANTS A stage 2 investigative study was conducted including development (stage 2a) and exploration (stage 2b) of transperitoneal and retroperitoneal RAP performed in 55 patients at an urban tertiary university department of urology. SURGICAL PROCEDURE Retroperitoneal RAP was performed with the patient in full flank position using a 12-mm Hasson-style optical port at the tip of the 12th rib, plus two operative 8-mm robotic trocars and an assistant 5-mm port. The stenotic ureteropelvic junction was excised, the ureter was spatulated, and a dismembered pyeloplasty was performed in all cases. Transperitoneal RAP was performed with the patients in the 60° flank position. The optical port is in the umbilical area, plus two 8-mm operative robotic ports and one 5-mm assistant port. The pyeloplasty technique is similar to the retroperitoneoscopic approach. In both groups, the stent can be positioned in an anterograde or retrograde fashion. MEASUREMENTS Success consisted of no evidence of obstruction on computed tomography urography or mercaptoacetyltriglycine-3 diuretic renal scan, no postoperative symptoms, and no further treatment. RESULTS AND LIMITATIONS Thirty-six patients underwent retroperitoneoscopic RAP and 19 transperitoneal RAP for UPJO. All the procedures were completed with robotic assistance. The overall objective success (measured by diuretic renal scan and/or imaging techniques) was 96% with two cases of recurrence (both in the retroperitoneal group). The main limitation was the short follow-up, although all patients reached at least a 6-mo follow-up. CONCLUSIONS RAP performed either retroperitoneally or transperitoneally was revealed as a feasible and reproducible surgical option for the treatment of UPJO, offering a subjective optimal plasty reconfiguration at short follow-up.

Robot-assisted uretero-ureterostomy for iatrogenic lumbar and iliac ureteral stricture: Technical details and preliminary clinical results

BACKGROUND Although the incidence of iatrogenic ureteral strictures is low, the treatment remains challenging. OBJECTIVE To report our technique of robot-assisted uretero-ureterostomy (RAUU) for adults with iatrogenic lumbar and iliac stricture. DESIGN, SETTING, AND PARTICIPANTS A descriptive study was performed by our department. Since April 2009, five patients underwent RAUU: Two patients had developed a lumbar or iliac ureteral stricture following a ureterorenoscopy, one had ureteral catheter positioning, one had colon surgery, and one had resection of retroperitoneal cystic lymphangioma. Preoperative evaluation includes history, computed tomography (CT) scan, and mercaptoacetyltriglycine-3 (MAG3) diuretic renal scan. SURGICAL PROCEDURE A flank position was used for all patients with lumbar stenosis. A supine position with the bed turned 30° was required for iliac stricture. The optical port, two 8-mm robotic ports, and one 5-mm assistant port were used. A precise definition of the site and extension of the stricture was done using the flexible ureterorenoscope. After the stricture resection, the anastomosis was performed with two running sutures on a ureteral double-J stent. MEASUREMENTS Success was defined as no postoperative symptoms and evidence of no obstruction at the CT/urography and at the MAG3 scan at 6-mo follow-up. RESULTS AND LIMITATIONS RAUU was technically feasible in all five patients. Average operating time was 135min, and median hospital stay was 3 d. No significant complications occurred. Absence of stricture recurrence and no reduction of kidney function were confirmed by CT/urography and MAG3 scans. At a mean follow-up of 8 mo, all patients were asymptomatic. The main limitations were the short follow-up and the small sample size. CONCLUSIONS RAUU is feasible and safe for repairing iatrogenic lumbar and iliac ureteral strictures. The flexible ureterorenoscopy is useful to localise the obstruction and to correctly define its site and extension to spare as much ureter as possible.

Radical prostatectomy represents an effective treatment in patients with specimen-confined high pathological Gleason score prostate cancer.

To date, only a few studies have addressed the long‐term oncological outcomes of radical prostatectomy (RP) in patients with pathological Gleason score ≥ 8 prostate cancer. According to these reports, some individuals with pathological Gleason score ≥ 8 may benefit from RP, with cancer‐control outcomes comparable with those of patients with low‐ and intermediate‐risk prostate cancer. The presence of pathological Gleason score 8–10 represents a poor prognostic factor in the outcome of men with prostate cancer. However, in patients with specimen‐confined disease, RP and bilateral PLND provided long‐term cancer‐control outcomes similar to those of patients with more favourable disease characteristics.

Urethral Lift for Benign Prostatic Hyperplasia: A Comprehensive Review of the Literature

Current treatments for benign prostatic hyperplasia (BPH) include watchful waiting, medical therapy, and interventional procedures. The post-surgical complication profile and the early discontinuation of medical therapy are significant drawbacks of the established approach and stimulate the search for less-invasive approaches. Our aim is to provide a comprehensive review all available literature on prostatic urethral lift (PUL), presenting an overview of safety, indications, surgical technique and results of the procedure, and to evaluate the potential role it could play in the treatment of BPH. A comprehensive search was conduct on PubMed and Scopus database to identify original articles in English dealing with PUL without any limit to publication date. Keywords used were prostatic urethral lift, urethral lifting, Urolift, benign prostatic hyperplasia and minimally invasive therapy. The PUL seems to offer a better IPSS improvement when compared to medical therapy, but the result is inferior when compared to surgical therapy. Published studies report an absence of degradation of erectile or ejaculatory function after treatment, which appears a noteworthy benefit of PUL. Additional advantages of the PUL are a better complication profile in comparison to other surgical therapies and the use of a local anesthesia, sometimes without postoperative catheterization. The PUL, a novel, minimally invasive treatment option for men affected by BPH, presents a promising potential although it is clear that PUL is not a substitute for traditional ablative surgical approach, as this procedure requires a scrupulous selection of the patient.

The Relationship Between Continence and Perineal Body Tone Before and After Radical Prostatectomy: A Pilot Study

Recent preliminary studies showed that tonic‐trophic characteristics of the pelvic muscles are related to postoperative male urinary incontinence. The aim of the current study was to test whether perineal body tone (PBT), evaluated using the Beco perineometer (Perineocaliper), is related to urinary continence recovery after robot‐assisted laparoscopic prostatectomy (RALP).

Ischemia of the glans 24 hours after circumcision: A case report and therapeutic solution:

Introduction: Circumcision is a common surgical procedure, typically performed under local anesthesia and somehow also as outpatient clinic. Although complications are rare and most frequently related to the procedure itself, ischemia of the glans may occur as a major complication and can be related to local ischemia following dorsal penile nerve block. Case description: We describe the case of a 33-year-old patient who underwent circumcision at our institution and, 24 h after the procedure, developed an acute ischemia of the glans; a re-intervention was performed in emergency setting to ensure a large, not-tightened circular suture under the glans, and low-molecular-weight heparin and antiplatelet therapy was introduced to achieve anti-coagulative/antiaggregant effects. After 48 h, the skin returned to its normal color and in 7 days the penile glans achieved complete remission of the ischemic aspect. A 6-month follow-up confirmed regular outcomes with normal erectile functions. Conclusion: The treatment we proposed to treat acute post-circumcision ischemia of the glans is a simple and effective one, with a perfect aesthetic and functional outcome observed within 4 weeks and confirmed at 6-month follow-up.

Single-Site Robotic Pyeloplasty Employing the Novel-Dedicated da Vinci Platform

Laparoendoscopic single-site surgery (LESS) was proposed with the aims to further reduce the limited invasiveness of conventional laparoscopy. Nevertheless, LESS remains a challenging surgical technique requiring great surgical skills, due to the lack of triangulation and reduced instruments movement. These limitations emerged more clearly when using LESS approach for reconstructive procedures such as pyeloplasty, in which proper suturing is mandatory to provide adequate repair of the stenotic upper urinary tract junction (UPJ).