Mustafa Bilal Tuna

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection.

To determine an accurate incidence of lymphocele formation and its sequela after robot‐assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience

OBJECTIVE To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. MATERIALS AND METHODS The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. RESULTS Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. CONCLUSION The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

Conversion to Hand Assistance May Prevent Conversion to an Open Procedure in Standard Laparoscopic Nephrectomy

BACKGROUND AND PURPOSE Laparoscopic surgery has received wide acceptance within the urologic community. Conversion from standard laparoscopy to the open technique may sometimes be necessary. Conversion to an open procedure may have negative implications for both the surgeon and the patient. Conversion to hand-assisted laparoscopy under these circumstances, however, may obviate open surgery. We intended to review our results and emphasize the efficacy and safety of conversion to hand assistance during standard laparoscopy when necessary. PATIENTS AND METHODS We retrospectively reviewed the results of laparoscopic nephrectomies performed by one surgeon. Demographic and perioperative data were noted. Conversions from standard laparoscopy were analyzed in detail. RESULTS A total of 161 laparoscopic nephrectomies were performed. Conversion was deemed appropriate in 6 of 150 standard laparoscopies. Surgery was successfully completed in five with hand assistance. The reason to convert was failure to progress in three patients and control of hemostasis in two patients. Open surgery was performed in a patient who could not tolerate pneumoperitoneum. CONCLUSION Conversion to hand-assisted laparoscopy is safe and effective when the surgeon decides to convert from standard laparoscopy. Conversion to hand assistance may prevent conversion to an open procedure in these situations.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve)

PURPOSE To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

Serum levels of growth factors in patients with urinary bladder cancer

Abstract Background: Altered signalling of human epidermal growth factor receptor-2 (HER-2/neu), insulin-like growth factor 1 (IGF-1) and epidermal growth factor (EGF) have been shown to play important role in tumor development and progression in various cancers. Their serum levels may be reliable indicator for diagnosis and progression of cancer. Objective: To examine the serum levels of soluble HER-2/neu (sHER-2/neu), IGF1 and EGF in patients with urinary bladder cancer (UBC). Material and methods: Serum levels of sHER-2/neu, IGF1 and EGF were measured by enzyme-linked immune assay in newly diagnosed, untreated patients with UBC. Results: In the patient group, sHER-2/neu level was found to be increased, IGF1 level was found to be decreased in comparison to those in the control group. Although serum level of sHER-2/neu was lower in the patients with Ta stage than that in the patients with T1 and T2 stages, this difference was not at a statistically significant level. Conclusion: Serum level of sHER-2/neu is increased in patients with UBC. Despite the lack of a significant association between sHER-2/neu level and pathological pT stage, sHER-2/neu may be a promising marker for UBC but IGF-1 and EGF have not such a potential.

MP93-01 MODIFIED ANASTOMOSIS TECHNIQUE DURING ROBOT ASSISTED RADICAL PROSTATECTOMY: PREVENTION OF URETHRAL RETRACTION AND IMPROVEMENT OF EARLY CONTINENCE

INTRODUCTION AND OBJECTIVES: To report our new vesicourethral anastomosis technique during robot assisted radical prostatectomy and test its impact on the immediate and early continence rates. METHODS: Between January-June 2016, 60 patients were enrolled in the study and data collected prospectively. Modified vesicourethral anastomosis was performed by a single surgeon. The new technique was based on stabilizing the posterior urethra with anastomosis sutures before transecting the prostatic urethra. Two 3/ 0 barbed sutures were passed from the urethra at 5 o clock and 7 o clock positions and then used for vesicourethral anastomosis. This cohort of patients (Group I, 60 pts) was compared with the most recent consecutive patients in whom standard continuous running anastomosis technique was used prior to initiating the new technique (Group II, 60 pts). Post catheter removal 1st week and 1st month continence status were compared with the standard technique using ICIQ-SF form and 1st month overactive bladder questionnaire form. Preoperative ICIQ-SF scores were aslo obtained for both groups but there were no statistical significant distance between groups. RESULTS: Groups were compared in terms of Prostate specific antigen (EBL), age, body mass index (BMI), American society of anesthesiology score (ASA), prostate volume, final gleason score, operation and anastomosis time, and estimated blood loss (EBL). Also surgical margin positivity, bladder neck reconstruction rate, lymph node invasion rate were compared. Only statistically significant difference was encountered in modified anastomosis group in terms of age; group II was younger compared to group I. (61+7.5 vs. 64+7.6, p<0.05). For the 1st week of post catheter removal, mean ICIQ-SF scores for group I and -group II were 4.1+5.7 vs. 12.1+4.1 respectively (p<0.001). Recatheterization was needed in ;4 of 60 patients in Group 1 and 1 of 60 patients in Group 2; (p>0.05). Similarly; 1st month ICIQ-SF scores for group II and group I were 10.8+4.4 vs. 2.6 +4.3, respectively (p<0.001). Overactive bladder questionnaire scores were also compared. There was a statistically significant difference between two groups in favor of group I (18+7.7 vs. 5.3+6.2) (p<0.001). CONCLUSIONS: Modified anastomosis technique seems to have better early continence rates compared to the standard technique. Moreover, overactive bladder symptoms were significantly less common with the novel anastomosis technique. Further randomized studies are needed to better evaluate the effect and reproducibility of this new technique.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes

Background and Objectives: “Trifecta” in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes. Methods: This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant. Results: A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient. Conclusions: Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Prevention of Urethral Retraction with Stay Sutures (PURS) During Robot-Assisted Radical Prostatectomy Improves Early Urinary Control: A Prospective Cohort Study

OBJECTIVE To evaluate early continence rates with a novel modified vesicourethral anastomosis technique based on prevention of urethral retraction using anastomosis sutures as stay sutures (PURS) during robot-assisted radical prostatectomy. MATERIALS AND METHODS Sixty patients operated by a single surgeon were enrolled and data collected prospectively. This cohort was compared with another consecutive 60 patients operated with standard anastomosis. The new technique is based on preventing urethral retraction of the posterior urethra with two anastomosis sutures being used as stay sutures. The outcomes were prospectively followed and groups compared regarding early continence. International Consultation on Incontinence Questionnaire Short Form was used to assess incontinence and its impact on the quality of life. Pad use (yes or no pads) was evaluated as a more stringent criterion. RESULTS Preoperative patient characteristics were similar between the two groups. Anastomosis was completed faster in PURS group (15.1 vs 18.5 min, p = 0.05). At postoperative week 1 and month 1, the severity and bother of incontinence were significantly less in the PURS group (12.7 vs 4.1 and 10.1 vs 2.6, p < 0.001). PURS cohort reported significantly superior pad-free rates at both postoperative month 1 (73% vs 35%, p < 0.0001) and month 3 (83% vs 53%, p = 0.0004). On multivariable analysis, younger age and the new anastomosis technique were two independent predictors to improve early continence. Four patients in modified anastomosis group (4/60) and 1 in standard anastomosis group (1/60) necessitated temporary urethral recatheterization because of urinary retention. CONCLUSION We describe a simple and time-efficient modified urethrovesical anastomosis technique by using anastomosis sutures as stay sutures to prevent perineal retraction of the urethral stump. Our results demonstrated that the technique is an independent factor impacting early recovery of urinary continence. Future randomized controlled studies would be required to further test the reproducibility of this technique.

Minimizing Ports During Robotic Partial Nephrectomy.

Background and Objective: Robotic upper urinary tract surgery is in most of the cases performed utilizing a standard 5 port configuration. Fewer ports can potentially produce a less invasive operation. Taking in consideration the above we report a novel technique for robot assisted laparoscopic partial nephrectomy utilizing fewer ports and we test its feasibility and safety profile. Methods: Data on 11 robot-assisted laparoscopic partial nephrectomies performed by using our technique from February 2015 through June 2015 were retrospectively analyzed. The robotic platform used was DaVinci Xi (Intuitive Surgical, Inc., Sunnyvale, California, USA) with a 3-arm setup. The AirSeal system (SurgiQuest, Milford, Connecticut, USA) was used as a port allowing simultaneous introduction of 2 instruments for the bedside surgeon, obviating the need for an additional (fourth) robotic arm. A long suction-and-irrigation device and atraumatic grasping forceps were used. Both instruments were introduced through the trocar of the AirSeal system, making simultaneous introduction and use possible. We preferred the long suction-and-irrigation device, because it minimizes collision of the instruments. Results: Mean age and BMI of the patients were 55 ±14.6 y and 29.18 ± 6.85, respectively. Seven tumors were on the right side and 4 were on the left. The mean size of the tumors was 32.45 mm (± 11.31). Surgical time was 132.2 minutes (±37.17), with an estimated blood loss and ischemia time of 103.63 mL (±65.92) and 16.72 minutes (±9.52), respectively. One patient had postoperative bleeding that was resolved without transfusion. The median hospitalization period was 3.9 d (±0.53). Loss of intra-abdominal pressure was not observed, and pressure was stable at 10 mm Hg. Conclusion: The AirSeal System and its valveless trocar eliminated the need for an additional port placement in our series. The technique is feasible, safe, and reproducible; therefore, it may be implemented in selected cases of robot-assisted partial nephrectomies.