Rishi Nayyar

Outcome analysis of robotic pyeloplasty: a large single‐centre experience

Study Type – Therapy (case series)
Level of Evidence 4

Potential of magnetic resonance spectroscopic imaging in predicting absence of prostate cancer in men with serum prostate-specific antigen between 4 and 10 ng/ml: a follow-up study.

OBJECTIVES Screening for prostate cancer using serum prostate-specific antigen (PSA) determination has a positive predictive value of only 30% to 42% for a PSA level between 4 and 10 ng/mL. Magnetic resonance spectroscopic imaging (MRSI), which identifies cancer on the basis of changes in cellular metabolite levels, might be able to identify patients with noncancerous PSA elevation and help avoid unnecessary biopsies. We tested this hypothesis by evaluating the incidence of prostate cancer in men with a PSA level of 4 to 10 ng/mL and a negative MRSI study. METHODS A total of 155 men underwent a three-dimensional proton MRSI of the prostate before transrectal ultrasound-guided biopsy for clinical indications. MRSI was performed using an endorectal coil on a 1.5-T magnetic resonance scanner. Patients with no voxels positive for malignancy underwent standard sextant biopsy, and additional MRSI-targeted biopsies were obtained in men with suspicious or malignant voxels. Patients with a biopsy negative for cancer underwent repeat serum PSA estimation every 6 months for a minimum of 18 months. RESULTS Of the 155 men, 36 (mean PSA level of 6.47 ng/mL, range 4.25 to 9.9) had no malignant voxels on MRSI. None of them were positive for cancer on biopsy. Of these 36 men, 26 completed at least 18 months (mean 26.9, range 18 to 44) of follow-up. Four patients required repeat biopsies and one, with a persistently elevated PSA level was diagnosed with prostate cancer 29 months after the initial MRSI. CONCLUSIONS The results of our study have shown that prostate biopsy can be deferred in patients with an increased serum PSA of 4 to 10 ng/mL if their MRSI does not show any malignant voxels.

Robotic Repair of Primary Symptomatic Obstructive Megaureter with Intracorporeal or Extracorporeal Ureteric Tapering and Ureteroneocystostomy

OBJECTIVE To describe the technique, feasibility, and effectiveness of robotic ureteric tapering (intra- or extracorporeal) and ureteroneocystostomy with and without ureteric stones retrieval in patients with symptomatic primary obstructive megaureter. MATERIALS AND METHODS Seven patients (one bilateral) (mean age: 28.3 years) with symptomatic or complicated congenital primary obstructive megaureter were considered for robot-assisted laparoscopic reconstruction. All surgical steps were performed purely robotically via transperitoneal access by single surgeon including ureteric reimplantation and retrieval of ureteral stones, except in two patients where ureteral tapering was done extracorporeally. The relevant perioperative details, complications, and functional outcomes were analyzed. Besides clinical follow-up, objective evaluation was done with diuretic renogram and intravenous urography. RESULTS Total mean operative time and surgeons console time were 142.5 and 127.5 minutes (range: 115-230 and 100-210), respectively, with an estimated blood loss of less than 50 mL. Mean analgesic requirement was 175 mg of diclofenac sodium and oral feeds were started after 12 hours (range: 7-16). Average hospital stay was 3.2 days (range: 2-6). Complications included one case of perioperative urinary tract infection. Average follow-up period was 16 months (range: 11-20). Follow-up ultrasonography and intravenous urography confirmed reduction of hydronephrosis and good drainage. The mean split renal function of the salvaged kidney was 41.2% at last follow-up when compared with preop average value of 41.3%. CONCLUSIONS Robotic repair and removal of ureteric stones in primary symptomatic obstructive megaureter is safe, feasible, and effective with either intracorporeal or extracorporeal ureteric tapering. It has minimal perioperative morbidity and durable success as demonstrated with subjective and objective evaluation.

Potential of (1)H MR spectroscopic imaging to segregate patients who are likely to show malignancy of the peripheral zone of the prostate on biopsy.

To evaluate the potential of MR spectroscopic imaging (MRSI) to segregate patients who, upon prostate biopsy, are more likely to show a malignancy in the peripheral zone (PZ) of the prostate gland.

Surgical techniques: robotic bladder diverticulectomy with the da Vinci-S surgical system

Bladder diverticulectomy is a surgical operation for symptomatic or large bladder diverticula. Typically, bladder diverticula are because of infravesical obstruction, although congenital diverticula can occur that may be large and symptomatic. The ability to excise the diverticulum completely, avoid important adjacent structures, and close the bladder defect in a watertight fashion are key fundamentals to this operation. Traditionally done via an open extravesical, intravesical, or combined approach, bladder diverticulectomy can now be done in a minimally invasive fashion. Both laparoscopic and robot-assisted methods have clear advantages over open surgery, including smaller incision, reduced pain, improved cosmesis, and reduced blood loss, with an equivalent functional result. Large bladder diverticula, particularly those involving the ureteric orifice which required ureteric reimplantation, were often considered beyond the scope of conventional laparoscopy. Recently, use of robotic technology as a means of facilitating laparoscopic excision of bladder diverticula has provided the ability to treat large and more complex diverticula. Advantages of the robotic approach are the finer precision and dexterity of the instruments coupled with three-dimensional imaging. Although there are several case reports describing pure laparoscopic diverticulectomy, as far as we are aware there are no published reports of robotic bladder diverticulectomy. This paper will outline a safe and reproducible surgical technique for performing robotic bladder diverticulectomy using the da Vinci-S surgical system.

Critical appraisal of technical problems with robotic urological surgery

Study Type – Therapy (case series)
Level of Evidence 4

Transmesocolic Robot-Assisted Pyeloplasty: Single Center Experience

PURPOSE To demonstrate the technical feasibility of the transmesocolic approach of robotic pyeloplasty for left ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS Between July 2006 and December 2007, 60 patients underwent robot-assisted pyeloplasty that included 33 cases on the right side and 27 cases on the left side. Of the 27 left-side cases, 24 were performed using a transmesocolic approach. Three left-side surgeries were performed by mobilizing the colon because of associated accessory vessel and renal calculi. A pure robot-assisted dismembered reduction pyeloplasty with excision of the ureteropelvic junction was performed in all cases. RESULTS The mean operative time was 125.33 minutes. The time to perform the anastomosis was 43.58 minutes, and mean blood loss 38.7 mL. Average hospital stay was 2.5 days, and the drain was removed within 48 hours. One patient had prolonged drainage with fever because of a misplaced ureteral stent. Of the 24 patients, 23 were followed for 1 year and 1 was lost to follow-up. No patient demonstrated clinical or radiographic evidence of repeated obstruction. CONCLUSION In the transmesocolic approach, mobilization of the colon is not necessary, and the UPJO can be approached directly after incising the mesocolon. This approach is safe and feasible in patients with a thin mesentry and when extensive mobilization of the kidney is not needed for any associated problems. The technique is highly effective with durable success rates similar to those of open surgery.

Prognostic Factors Affecting Progression and Survival in Metastatic Prostate Cancer

Purpose: To evaluate the role of age, Gleason score, prostate-specific antigen (PSA), PSA doubling time (PSADT), and PSA half-time (PSAT1/2) as prognostic factors in metastatic prostate cancer to predict long-term outcome. Patients and Methods: 412 patients with metastatic prostate cancer diagnosed after January 1995, with at least 6 months of follow-up, were enrolled. Serum PSA was determined at diagnosis and every 3–6 months thereafter. All patients underwent medical or surgical castration. End points of the study were either death or disease progression. Univariate and multivariate Cox proportional hazard analysis was used to evaluate prognostic factors. Results: Median progression-free and overall survival was 3 and 5.7 years. Patients aged ≤65 years at diagnosis, high baseline PSA and high nadir PSA were associated with poor overall survival. Patients with a PSAT1/2 of <6 months, high baseline alkaline phosphatase, and PSADT of <1 month had significantly poorer progression-free and overall survival. Conclusion: Prostate cancer is a common malignancy in the elderly population. We have found that younger patients with high baseline and nadir PSA, shorter PSADT and PSAT1/2 have poorer overall and progression-free survival.

Robot-assisted laparoscopic pyeloplasty with stone removal in an ectopic pelvic kidney.

The authors suggest that robotic technology may be used for pyeloplasty in difficult cases of ectopic position and concomitant stones.

Comparative Analysis of Percutaneous Nephrolithotomy in Patients with and without a History of Open Stone Surgery: Single Center Experience

PURPOSE To report our experience of percutaneous nephrolithotomy (PCNL) in patients who were treated previously with open stone surgery. PATIENTS AND METHODS Sixty-six patients with a history of open stone surgery (group 1) were compared with 90 patients without previous surgical intervention (group 2). Both groups were almost similar in demographic profile (age, sex, laterality, stone burden and success rate, body mass index, and location of stones. Patients who had tubeless or bilateral PCNL were excluded from the study. Antibiotics were administered prophylactically to all the patients. Patients with positive urine culture were treated with appropriate antibiotics, and sterile urine was ensured before surgery. Normal saline was used as irrigation fluid. Statistical analysis was performed using the chi-square test for qualitative variables and the Student t test for quantitative variables. A P value <0.05 was considered significant. RESULTS Mean time interval between previous open surgery to PCNL in group 1 was 7.6 (range 1-18) years. Mean operative time was longer in group 1 (88.4 min vs 80.2 min), but it was not statistically significant. Average drop in hemoglobin level was comparable in both groups (2.3 vs 2.1 g/dL). A significant number of patients in group 1 needed a metallic dilator for tract dilation. Hospital stay and postoperative analgesic requirement were similar in both groups. Postoperative and intraoperative complications were also similar in both groups. CONCLUSION Previous open stone surgery does not alter the outcome of subsequent PCNL significantly except that these patients more frequently need relook procedures for achieving complete clearance.