ANTEMORTEM DIAGNOSIS AND SUCCESSFUL TREATMENT OF A COMPLETE MOLAR PREGNANCY IN A GERIATRIC BONOBO ( PAN PANISCUS).

A 47-yr-old multiparous female bonobo ( Pan paniscus) tested positive for pregnancy on a routine urine test. Because this geriatric animal was considered postreproductive, oral contraception had been discontinued. Sequential transabdominal ultrasound evaluations were performed under voluntary behavior and revealed that the uterus contained a mass of heterogenous tissue which was rapidly increasing in size. Due to a lack of normal fetal development and the ultrasonographic appearance of the uterine tissue, a molar pregnancy was suspected. Ovariohysterectomy was performed, and a complete hydatidiform mole was confirmed through human chorionic gonadotropin levels as well as gross and histological examination of the uterus. To the authors' knowledge, this is the first time a complete molar pregnancy has been reported antemortem in a nonhuman great ape, although a single case of partial hydatidiform mole was previously documented in a chimpanzee on postmortem examination. This case describes the successful medical and surgical management of complete molar pregnancy in a bonobo and provides support for extending the age range of birth control recommendations in geriatric captive great apes that exhibit active breeding behavior.

Partial nephrectomy in a patient with dwarfism.

We describe the case of a 50-year-old male with achondroplastic dwarfism who presents with a renal mass in his left kidney concerning for renal cell carcinoma. The patient successfully underwent a robotic partial nephrectomy, which revealed a T1a renal cell carcinoma. The tumor was excised successfully without any intraoperative complications demonstrating that a robotic partial nephrectomy is technically both safe and effective in patients with achondroplastic dwarfism.

Controversies in Robotics: Open Versus Robotic Radical Cystectomy.

Open radical cystectomy (ORC) remains the gold standard for treatment of muscle-invasive bladder cancer and certain cases of high-risk noninvasive bladder cancer. However, ORC is associated with significant morbidity, and there is promise of improved outcomes with the emergence of minimally invasive surgery. Because of the increased adoption of robotic radical cystectomy (RRC), we sought to review the current literature on the robotic approach. We explored the surgical techniques, perioperative and postoperative complications, oncologic and functional outcomes, and quality of life of patients with RRC versus ORC. Current data appear to favor RRC in perioperative outcomes and patient recovery, although RRC continues to be associated with longer surgical times and higher costs. Oncologic data are also promising, however data on long-term oncologic outcomes are insufficient. To date, there is evidence of similar functional outcomes between RRC and ORC continence, but there is a paucity of rigorous, standardized studies on health-related quality of life for continent versus incontinent diversion. Even as use of RRC steadily grows, there is a lack of consensus on the type of approach and urinary diversion that is optimal. We assessed the influence of surgeon experience on the totally intracorporeal urinary diversion and its feasibility to be widely adopted. We aimed to answer the question of whether there are significant benefits to RRC, and furthermore, of the effect of the approach on the choice of urinary diversion.

Decreasing suprapubic tube-related injuries: results of case series and comprehensive literature review.

Bowel-related injuries are known complications of suprapubic tube (SPT) catheterization placement. A literature review was conducted to determine identifiable risk factors for bowel injury. Results on the analysis of 25 cases are presented along with a proposed algorithm to aid in choosing between open, percutaneous, and image-guided methods of placement.

An updated report on complications following robotic prostatectomy: results of an unbiased prospective database.

INTRODUCTION: The application of robotic-assisted radical prostatectomy has increased considerably over the past decade, but there remains a paucity of standardized complications reporting associated with this procedure. The complications literature regarding robotic prostatectomy is wrought with limitations, variability, and bias making meaningful comparisons between surgical series difficult. MATERIALS AND METHODS: From November 2006 to December 2010, a total of 575 patients were evaluated. Data were assimilated through an IRB-approved blinded prospective database by an independent third party committee. Patients were followed prospectively for 30 days postoperatively. The Modified Clavien system was utilized to grade complications. Grade I and II complications were classified as minor, while grade III, IV, and V were considered major complications. Multiple complications in individual patients were recorded as separate events. Our initial experience and that of our most recent were compared. Age, body mass index, American Society of Anesthesiologists score, Gleason grade, prostate specific antigen, prostate volume, and complications were evaluated. RESULTS: Of the 575 patients, 482 (83.8%) had an ideal perioperative course. In the remaining 93 (16.2%) patients, there were 117 complications. Minor complications occurred in 84 (14.6%) and major complications arose in 15 (2.6%) patients. When the first 500 patients were divided into subsets of 100 patients, a linear regression analysis demonstrated no significant difference in overall complications among the five quintiles (p=0.17). The first quintile was found to have a significantly higher major complication rate compared with the second quintile (p=0.05). The subsequent quintiles exhibited no significant change in major complication rate. CONCLUSIONS: As a surgeon progresses through the learning curve, there is a stable overall complication rate with a drop in major complications after the first 100 cases.

Hand-assisted laparoscopic versus robot-assisted laparoscopic partial nephrectomy: comparison of short-term outcomes and cost.

INTRODUCTION: Robot-assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) have become standard for the surgical management of small renal masses (SRMs). However, no studies have evaluated the short-term outcomes or cost of RALPN as compared with hand-assisted laparoscopic partial nephrectomy (HALPN) in a standardized fashion. METHODS: A retrospective review of all patients who underwent HALPN or RALPN from 2006 to 2010 were assessed for patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, radiographic tumor size, nephrometry (radius, endo/exophytic, nearness to collecting system, anterior/posterior, lines of polarity [RENAL]) scores, operative and room times, hospital length of stay (LOS), estimated blood loss (EBL), requirement of hilar vessel clamping, warm ischemia time (WIT), pre- and postprocedural creatinine and hemoglobin levels, and complications. Total costs of the procedures were estimated based on operating room component (operative staff time, anesthesia, and supply) and hospital stay cost (room and board, pharmacy). A robotic premium cost, estimated based on the yearly overall cost of the da Vinci S surgical system divided by the annual number of cases, was included in the RALPN cost. Cost figures were obtained from hospital administration and applied to the mean HALPN and RALPN patient. RESULTS: Forty-seven patients underwent HALPN since 2006 and 21 patients underwent RALPN since 2008. ASA, BMI, EBL, tumor size, nephrometry score, positive margin rate, change in creatinine, change in hemoglobin, morphine equivalents used, and complication rate were all similar in both groups (p>0.05). Room time and operative time were significantly shorter for the HALPN cohort (p=0.001) whereas LOS was significantly shorter in the RALPN cohort (p=0.019). Despite the shorter LOS, RALPN was associated with a $1165 increased cost, mainly due to increased operating room time and premium cost of the robot. CONCLUSIONS: While early in our experience, RALPN offered no significant advantage in short-term outcomes over HALPN and was associated with an increased cost of over $1150.

Dedicated robotics team reduces pre-surgical preparation time.

CONTEXT: Robot-Assisted Laparoscopic Radical Prostatectomy (RALRP) requires significant preoperative setup time for the room, staff, and surgical platform. The utilization of a dedicated robotics operating room (OR) staff may facilitate efficiency and decrease costs. AIMS: We sought to determine the degree to which preoperative time decreased as experience was gained. MATERIALS AND METHODS: A total of 476 patients with a mean age of 60.2 years were evaluated (11/2006 to 1/2010). Data was assimilated through an institutional review board approved blinded, prospective database. Utilizing time from patient arrival in the OR to robot docking as preoperative preparation, our experience was evaluated. Age, body mass index (BMI), and American Society of Anesthesiologists risk scores (ASA) were compared. STATISTICAL ANALYSIS USED: Analysis of variance; Two-sample t-test for unequal variances. RESULTS: The first and last 100 cases were found to have similar age (P=0.27), BMI (P=0.11), and ASA (P=0.09). The average preoperative times were 66. 4 and 53.4 min, respectively (P<0.05). The second 100 patients treated were found to have a significantly shorter preoperative time when compared to the first 100 patients (P<0.05). When the first 100 cases were divided into cohorts of 10 cases the mean preoperative time for the first through fourth cohorts were 80.5, 69.3, 78.8, and 64.7 min, respectively. After treatment of our first 30 patients we found a significant drop in preoperative time. This persisted throughout the remainder of our experience. CONCLUSIONS: From the time of patient arrival a number of tasks are accomplished by the non-physician operating room staff during RALRP. The use of a consistent staff can decrease preoperative setup times and, therefore, the overall length of surgery.

Virtual surgical planning: a novel aid to robot-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Incidental detection of small renal masses has significantly increased over the last two decades with the advent of cross-sectional imaging. The shift in stage has been met with a shift in treatment modality because the preservation of renal parenchyma can prevent adverse outcomes. Robot-assisted laparoscopic partial nephrectomy (RALPN) needs significant surgeon expertise, and preoperative planning is imperative. PATIENTS AND METHODS: Between December 2010 and September 2011, virtual surgical planning (VSP) was used in consecutive patients with renal tumors that were suspicious for renal-cell carcinoma who were undergoing RALPN by a single surgeon. Three-dimensional (3D) reconstructions were examined and manipulated preoperatively, and an operative plan formulated. Intraoperative anatomy and preoperative 3D reconstructions were compared in real time. RESULTS: A total of 10 patients underwent RALPN with preoperative VSP. Average patient age at intervention was 54.6 years and average tumor size was 4.3 cm (range 1.7-7.5 cm). Tumor laterality was evenly distributed. Nephrometry score ranged from 5A to 10P, and final tumor pathology results revealed malignancy in 80%. No complications occurred intraoperatively, and an excellent correlation was noted between preoperative 3D reconstruction and intraoperative anatomy. All patients underwent a successful partial nephrectomy with no positive margins on final pathology results. Mean length of surgery was 232.9 minutes (range 156-435 min), and mean estimated blood loss was 370 mL (range 75-1800 mL). Warm ischemia time ranged from 20 to 50 minutes (mean 33.9 min). Data regarding postoperative renal function were available for six patients with an average loss of function of 9.5% (range 2%-17%). CONCLUSIONS: The implementation of this novel technology has significantly improved our ability to plan RALPN preoperatively. Tumor depth and complexity of tumor resection are assessed and the appropriate operative intervention and approach planned. Tumor proximity to vascular structures and collecting system were reliably predicted and therefore anticipated. Overall, these advantages created a safer surgical endeavor.

Surgical complications of laparoscopic urological surgery.

OBJECTIVES: To describe the incidence, identification and management of common intraoperative complications, including vascular, urological, bowel and visceral complications, of laparoscopic urological surgery. METHODS: We searched the databases of PubMed and Medline for relevant English language reports, using the keywords 'laparoscopy', 'urologic' and 'complication'. RESULTS: The search yielded 967 papers in all, and a review of these yielded a total of 42 relevant papers. CONCLUSION: Despite its advantages, laparoscopic urological surgery is associated with complications having rates as high as 22%. As surgical volumes increase, the incidence and magnitude of complications have increased progressively. Meticulous surgical technique, surgeon experience, and a high degree of suspicion are necessary throughout the surgical endeavour. The intraoperative recognition and management of complications is mandatory.

An unbiased prospective report of perioperative complications of robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: To analyze and classified our single-institution experience with the perioperative complications associated with robot-assisted laparoscopic radical prostatectomy (RALRP). METHODS: A total of 239 patients with a mean age of 60.6 years were evaluated (January 2007 to June 2008). Data were collected through an institutional review board-approved blinded prospective database by an independent third party committee. The data-points accrued were set forth by a 5-member panel including 3 robotic urological surgeons (J. R., G. H., G. P.), the chief of general surgery (H. S.), and a member of the hospital's outcomes committee. The Modified Clavien system was used to grade complications, with grade I and II representing minor and grade III, IV, and V major complications. RESULTS: Of our 239 patients, 198 (82.9%) had an uneventful postoperative course, defined as discharged home from the hospital within 2 days postoperatively with no unscheduled procedures/studies/hospital admissions or emergency room visits. On review of the remaining 41 patients, 55 complications were found. Of these, 24 were grade I, 17 grade II, 7 grade IIIa, 5 grade IIIb, 1 grade IVa, and 1 grade V complications. There was 1 perioperative mortality (0.4%) attributed to a pulmonary embolism on autopsy. Blood loss data revealed 1 (0.4%) intraoperative transfusion and 9 (3.8%) postoperative transfusions. CONCLUSIONS: RALRP is associated with major and minor complication rates of 5.0% and 14.6%, respectively. Prospective and blinded data on complications associated with RALRP are lacking in the published data. Our prospective, unbiased data provide an important tool to help counsel patients on complications associated with robot-assisted laparoscopic radical prostatectomy.

Renal parenchyma thickness: a rapid estimation of renal function on computed tomography.

PURPOSE: To define the relationship between renal parenchyma thickness (RPT) on computed tomography and renal function on nuclear renography in chronically obstructed renal units (ORUs) and to define a minimal thickness ratio associated with adequate function. MATERIALS AND METHODS: Twenty-eight consecutive patients undergoing both nuclear renography and CT during a six-month period between 2004 and 2006 were included. All patients that had a diagnosis of unilateral obstruction were included for analysis. RPT was measured in the following manner: The parenchyma thickness at three discrete levels of each kidney was measured using calipers on a CT workstation. The mean of these three measurements was defined as RPT. The renal parenchyma thickness ratio of the ORUs and non-obstructed renal unit (NORUs) was calculated and this was compared to the observed function on Mag-3 lasix Renogram. RESULTS: A total of 28 patients were evaluated. Mean parenchyma thickness was 1.82 cm and 2.25 cm in the ORUs and NORUs, respectively. The mean relative renal function of ORUs was 39%. Linear regression analysis comparing renogram function to RPT ratio revealed a correlation coefficient of 0.48 (p < 0.001). The linear regression equation was computed as Renal Function = 0.48 + 0.80 * RPT ratio. A thickness ratio of 0.68 correlated with 20% renal function. CONCLUSION: RPT on computed tomography appears to be a powerful predictor of relative renal function in ORUs. Assessment of RPT is a useful and readily available clinical tool for surgical decision making (renal salvage therapy versus nephrectomy) in patients with ORUs.

Renal parenchyma thickness: a rapid estimation of renal function on computed tomography

Purpose: To define the relationship between renal parenchyma thickness (RPT) on computed tomography and renal function on nuclear renography in chronically obstructed renal units (ORUs) and to define a minimal thickness ratio associated with adequate function. Materials and Methods: Twenty-eight consecutive patients undergoing both nuclear renography and CT during a six-month period between 2004 and 2006 were included. All patients that had a diagnosis of unilateral obstruction were included for analysis. RPT was measured in the following manner: The parenchyma thickness at three discrete levels of each kidney was measured using calipers on a CT workstation. The mean of these three measurements was defined as RPT. The renal parenchyma thickness ratio of the ORUs and non-obstructed renal unit (NORUs) was calculated and this was compared to the observed function on Mag-3 lasix Renogram. Results: A total of 28 patients were evaluated. Mean parenchyma thickness was 1.82 cm and 2.25 cm in the ORUs and NORUs, respectively. The mean relative renal function of ORUs was 39 percent. Linear regression analysis comparing renogram function to RPT ratio revealed a correlation coefficient of 0.48 (p < 0.001). The linear regression equation was computed as Renal Function = 0.48 + 0.80 * RPT ratio. A thickness ratio of 0.68 correlated with 20 percent renal function. Conclusion: RPT on computed tomography appears to be a powerful predictor of relative renal function in ORUs. Assessment of RPT is a useful and readily available clinical tool for surgical decision making (renal salvage therapy versus nephrectomy) in patients with ORUs.

National trends in the use of antireflux procedures for children.

OBJECTIVE: The purpose of this study was to analyze recent nationwide trends in the use of and outcomes after antireflux surgery for children. METHODS: We conducted a retrospective cohort study of children (age: <18 years) undergoing antireflux surgery by using data from 1996 to 2003 from the Nationwide Inpatient Sample. Census data were used to calculate the population-based rates of procedures stratified according to age and presence of neurologic impairment. Multivariate analyses were performed to determine factors associated with length of stay and in-hospital death. RESULTS: During the study period, 48,665 antireflux procedures were performed for children in the US. Although procedure rates were generally higher in 2003 than in 1996, no trends in rates were observed among different age groups and census regions during the study period. The highest population-based procedure rates were observed among infants (49-101 procedures per 100,000 population). There was a significant decrease in the percentages of children undergoing antireflux procedures who were neurologically impaired between 1996 and 2003 (53% vs 40%). Neurologically impaired children had longer lengths of stay and higher mortality rates than did neurologically normal children. CONCLUSIONS: Although procedure rates have not changed, the use of antireflux surgery has evolved during the laparoscopic era, with a decreasing percentage of neurologically impaired children undergoing this procedure. Antireflux procedures were performed predominantly for infants, most of whom were neurologically normal. Neurologically impaired children remain a group at high risk for death after antireflux procedures.