P. Marchetti

Impact of Prostate Weight on Probability of Positive Surgical Margins in Patients With Low-risk Prostate Cancer After Robotic-assisted Laparoscopic Radical Prostatectomy

OBJECTIVE To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. METHODS The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. RESULTS A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. CONCLUSIONS Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing.

Short (≤ 1 mm) positive surgical margin and risk of biochemical recurrence after radical prostatectomy.

It has been suggested that a very short positive margin does not confer additional risk of BCR after radical prostatectomy. This study shows that even very short PSM is associated with increased risk of BCR.

Management of the Ventriculo-Peritoneal Shunt in Pediatric Patients During Robot-Assisted Laparoscopic Urologic Procedures

INTRODUCTION Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures. MATERIALS AND METHODS After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications. RESULTS We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen. CONCLUSIONS In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results.

Does robot-assisted laparoscopic ileocystoplasty (RALI) reduce peritoneal adhesions compared with open surgery?

To compare perioperative outcomes between open ileocystoplasty and robot‐assisted laparoscopic ileocystoplasty (RALI) in a porcine model, as objective data comparing outcomes between these two approaches in children with neurogenic bladder are lacking. We specifically examined differences in postoperative peritoneal adhesion formation between the groups.

Robotic technologies in surgical oncology training and practice

The modern-day surgeon is frequently exposed to new technologies and instrumentation. Robotic surgery (RS) has evolved as a minimally invasive technique aimed to improve clinical outcomes. RS has the potential to alleviate the inherent limitations of laparoscopic surgery such as two dimensional imaging, limited instrument movement and intrinsic human tremor. Since the first reported robot-assisted surgical procedure performed in 1985, the technology has dramatically evolved and currently multiple surgical specialties have incorporated RS into their daily clinical armamentarium. With this exponential growth, it should not come as a surprise the ever growing requirement for surgeons trained in RS as well as the interest from residents to receive robotic exposure during their training. For this reason, the establishment of set criteria for adequate and standardized training and credentialing of surgical residents, fellows and those trained surgeons wishing to perform RS has become a priority. In this rapidly evolving field, we herein review the past, present and future of robotic technologies and its penetration into different surgical specialties.

Traumatic testicular dislocation.

IntroductionTraumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region.Materials and methodsA review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012.ResultsSeven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it was possible to obtain a satisfactory orchidopexy with gonadal preservation.ConclusionsTraumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent.

V5-10 RIGHT RADICAL NEPHRECTOMY WITH DISSECTION OF THROMBUS IN THE INFERIOR VENA CAVA LEVEL III

INTRODUCTION AND OBJECTIVES: The renal cell carcinoma has a known tendency to spread forming tumor thrombus to the renal vein or inferior vena cava (4-10%) The level that reach the tumor, it’s in direct relation with the 5-years survival METHODS: We show a case of a male 58 years old patient with history of diabetes and smoking. The patient complains of hematuria that started ten months ago. In the general lab work, the patient was anemic with a hemoglobin of 8 gr/dL and a serum creatinine of 1.1 mg/mL. The CT-Scan showed an 18 cm right kidney tumor with a thrombus in the inferior vena cava up to the diaphragm (Level III) with no seen metastatic disease or malignant lymphnodes Anterior open nephrectomy was performed, followed by control of inferior vena cava which it’s open entirely to perform the thrombectomy. RESULTS: The estimated operative time was 260 minutes, with a bleeding of 1600ml, requiring 3 units of blood during the surgery. No complications was reported. The post-op management was in the ICU for only 24 hours, with a total of length of stay of 5 days. The patient evolved without any complication, showing in the control lab, a serum creatinine of 1.3 mg/dL. To the date there is no evidence of residual disease, clinical nor in the images. CONCLUSIONS: The radical nephrectomy it’s the standard of care in the, level III inferior vena cava thrombus, in the setting of kidney cancer. It should be done in patients in conditions to have surgery.

Early Retrograde Nerve Preservation During Robot-Assisted Radical Prostatectomy: Description of Technique and Potency Outcomes

Abstract Introduction: Antegrade nerve sparing (ANS) is commonly performed during robot-assisted radical prostatectomy (RARP). However, this approach provides limited observation of the neurovascular bundle (NVB) course with the potential risk for injury. Objective: Our technique of retrograde, early release of the NVB is described. Mid-term outcomes are presented. Methods: Over 8 months, 200 consecutive patients with a preoperative sexual health index male (SHIM) score >21 underwent athermal, full bilateral retrograde nerve sparing (RNS). Data were compared to a previous cohort of 146 consecutive patients in whom ANS was performed. Surgical Procedure: Key aspects of the technique include initial athermal seminal vesicle dissection followed by thorough development of the posterior plane. An interfascial plane of dissection is developed on the prostate laterally until it meets with the previously developed posterior plane. The course of the NVB becomes clear and the pedicle is now transected. NVB dissectio...