Reza Ghasemian

Acute segmental testicular infarction.

Abstract  We report a case of segmental testicular infarction occurring in a patient with sickle cell trait. A 20‐year‐old African American man presented with a complaint of sudden onset, acute severe left testicular pain for 24 hours. Scrotal ultrasound revealed a hypo‐echoic mass in the left testicle. The hypo‐echoic area demonstrated no blood flow in Doppler mode. Because malignancy could not be excluded, the patient underwent a standard inguinal testicular exploration. A partial orchiectomy was performed with complete excision of the lesion. Pathology revealed infarcted testicular tissue with no malignancy present. Further evaluation revealed that the patient had sickle cell trait unbeknownst to him.

Daclizumab induction/tacrolimus sparing: a randomized prospective trial in renal transplantation

Abstract: Tacrolimus inhibits lymphocyte responses by blocking calcium‐dependent signalling pathways important in IL‐2 generation. Daclizumab, a humanized monoclonal antibody, binds with high affinity to the Tac subunit of the IL‐2 receptor complex. We reasoned therefore that the absence of IL‐2R should permit lower doses of tacrolimus and thereby less toxicity. Twenty‐eight patients were randomized and followed for 6 months: Group 1, high dose (HD) tacrolimus (trough 12–17 ng/mL; n = 13); Group 2, low dose (LD) tacrolimus (trough 5–10 ng/mL; n = 15). All patients received daclizumab induction (2 mg/kg) on days 0 and 14, mycophenolate mofetil (2 g/d except for one patient who received 1 g) and rapid prednisone taper. Serious infections were minimal in both groups. Hospitalizations, for various reasons, were HD (n = 12) and LD (n = 6). All patients and grafts survived for the 6‐month study period. There was one rejection episode in a non‐compliant patient at 101 d. LD tacrolimus appears equally effective as HD tacrolimus in preventing rejection episodes and may be associated with fewer adverse events.

SURGICAL COMPLICATIONS RELATED TO ROBOTIC PROSTATECTOMY: PROSPECTIVE ANALYSIS

INTRODUCTION AND OBJECTIVES: Robotic assisted radical prostatectomy (RALP) is now readily available worldwide, but a recent study of Medicare beneficiaries has raised a concern with regard to surgical morbidity related to the procedure. We have performed a critical analysis of our RALP complication profiles, stratified by our learning curve. METHODS: We have reviewed the surgical complications of our first 618 RALP cases performed by a single surgeon since 2003. Surgical data including all complications within 1 year of RALP have been collected prospectively in our ongoing IRB approved prostate cancer database. Multivariate analyses were utilized to identify risk factors for complications. RESULTS: There were 85 (13.8%) patients who experienced perioperative complications, which consisted of 44 major (7.1%) and 41 minor (6.6%) complications. When stratified by our learning curve, there was a significant reduction in overall complications over time. Of major complications, 15 (2.4%) and 12 (1.9%) patients developed a bladder neck contracture and inguinal/incisional hernia at a median follow-up of 3 and 4 months, respectively. There was no mortality or perioperative transfusion in this cohort. No risk factors other than surgeon’s experience were associated with surgical complications. CONCLUSIONS: In our prospective analysis of RALP related complications, the surgeon’s learning curve appears to be the greatest factor in influencing surgical morbidities. Our results reinforce the current wisdom that the surgeon’s experience is the most critical factor in determining surgical outcomes. Careful patient selection and judicious use of the daVinci system are advised during an early learning curve of RALP to minimize surgical complications.

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic–robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic–robotic partial nephrectomy—or hybrid procedure—and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system® was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.