Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve.

INTRODUCTION: The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol. METHODS: After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis. RESULTS: Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50-82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191-370) and 80 min (range: 65-90), respectively. The median estimated blood loss was 300 cc (range: 50-500). The median length of stay was 8 days (range: 4-30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1-17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1-34). CONCLUSIONS: While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.

Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience.

Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi® system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi® system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer-Yes, No or Maybe?

While pelvic lymphadenectomy during radical cystectomy for bladder cancer is a well-established standard of care, the same does not hold true for upper tract urothelial carcinoma (UTUC). Indeed, a template-based lymphadenectomy is rarely, if ever, performed in conjunction with radical nephroureterectomy at most centres across the globe. While multiple studies have explored the staging and therapeutic role of lymphadenectomy in cases of UTUC, there remain large gaps in our understanding of the indications, extent and safety of this procedure as an adjunct to nephroureterectomy. This article elucidates the current knowledge on outcomes, benefits and complications of template-based lymphadenectomy during radical nephroureterectomy for UTUC. We also explore the current evidence-based guidelines on this controversial topic.

Does Continuation of Low-Dose Aspirin During Robot-Assisted Radical Prostatectomy Compromise Surgical Outcomes?

OBJECTIVE: To evaluate the perioperative outcomes and 90-day complication rates of continuation of low-dose aspirin through surgery in patients undergoing robot-assisted radical prostatectomy (RARP). A significant proportion of patients undergoing RARP are on antiplatelet medications for primary or secondary prevention of cardiovascular events. However, there is still a relative lack of data with regard to the advantages and complications of continuing these medications through surgery. MATERIALS AND METHODS: Our usual protocol of RARP entails continuation of low-dose aspirin (75 mg once a day) for patients who are already on antiplatelet agents. We conducted a retrospective audit of a prospectively maintained database of 116 cases of RARP performed by a single surgical team in 1 year. Patients were divided into low-dose aspirin group (AG) (n = 31) and nonaspirin group (NAG) (n = 85). The primary objective was to compare the 90-day complication rates to assess the safety profile. Secondary objective was to compare perioperative parameters such as estimated blood loss, blood transfusion rates, fall in hemoglobin (Hb) level, drain outputs on day 1, days to drain removal, lymph node yield, and margin positivity. Subgroup comparison was performed between patients on aspirin for primary prevention (n = 15) and NAG. RESULTS: Both groups were well matched for preoperative parameters except for significantly higher comorbidities and American Society of Anesthesiologists (ASA) score class in AG. Console time, blood loss, fall in Hb level, drain output, drain and catheter removal days, day of discharge, and lymph node yield were comparable. Margin positivity was significantly higher in NAG. Ninety-day complication rates were not significantly different between the two groups (p = 0.218) with only one major complication (Clavien-Dindo grade 4 hypotension requiring intensive care unit admission) in AG. Subgroup comparison demonstrated similar outcomes. CONCLUSION: Low-dose aspirin can be safely continued perioperatively during RARP, without increasing the bleeding-related complications and overall 90-day complication rates.

Robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma: An outcome analysis.

INTRODUCTION: Robot-assisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (E-LND) is the leading treatment option for nonmetastatic upper tract urothelial carcinoma. Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 11 consecutive cases of RANU + E-LND. To the best of our knowledge, our series represents the first published experience of this procedure from India. MATERIALS AND METHODS: RANU was performed in 11 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without re-docking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was re-docked to ensure completeness of pelvic lymphadenectomy. E-LND was performed in all the patients as per the templates described in previous studies. RESULTS: Median age was 67.5 years (range 52-71). Median console time and blood loss were 170 min (range 156-270) and 150 cc (range 25-500), respectively. Median hospital stay was 3 days (range 2-8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7-47). Median follow-up was 9 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last follow-up. CONCLUSIONS: A robotic approach to radical nephroureterectomy with E-LND is feasible and safe and does not appear to compromise the short-term oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery.

Ureterocalycostomy - final resort in the management of secondary pelvi-ureteric junction obstruction: our experience.

Ureterocalycostomy can be performed in patients in whom desired methods of treating secondary PUJ (Pelvi-Ureteric Junction) obstructions either failed or could not be used. In our study, one child and two adults in whom one redo-ureterocalycostomy and two ureterocalycostomies were performed for severely scarred PUJ. The causes for secondary PUJ obstruction were post-pyelolithotomy in one case, post-pyeloplasty and ureterocalycostomy for PUJ obstruction in the second patient and the third patient had long upper ureteric stricture post-ureteropyeloplasty due to tuberculosis. In all these cases ureterocalycostomy proved to be salvage/final resort for preserving functional renal unit.

Ureterocalycostomy - final resort in the management of secondary pelvi-ureteric junction obstruction: our experience

ABSTRACT: Ureterocalycostomy can be performed in patients in whom desired methods of treating secondary PUJ (Pelvi-Ureteric Junction) obstructions either failed or could not be used. In our study, one child and two adults in whom one redo-ureterocalycostomy and two ureterocalycostomies were performed for severely scarred PUJ. The causes for secondary PUJ obstruction were post-pyelolithotomy in one case, post-pyeloplasty and ureterocalycostomy for PUJ obstruction in the second patient and the third patient had long upper ureteric stricture post-ureteropyeloplasty due to tuberculosis. In all these cases ureterocalycostomy proved to be salvage/final resort for preserving functional renal unit