Robot-assisted retroperitoneal lymph node dissection: Feasibility and outcome in postchemotherapy residual mass in testicular cancer.

INTRODUCTION: We aimed to evaluate the surgical feasibility, complication, and oncological outcome of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in patients of testicular tumor with postchemotherapy residual retroperitoneal mass. METHODS: A total of 13 patients underwent RA-RPLND between January 2012 and September 2016 at our institute. A study was started on December 2015, so data were collected retrospectively and prospectively regarding patient demography, tumor characteristics, surgical, pathological outcome, and oncological outcome. RESULTS: RA-RPLND was successfully completed in all the 13 patients. Lateral approach was used in initial 12 patients with unilateral dissection in 11 patients and bilateral dissection after in 1 patient after repositioning in bilateral position. Supine robotic approach used in 1 patient. Median operative time was 200 min, median estimated blood loss was 120 ml, and median length of hospital stay was 4 days. The median yield of lymph node was 20. Three patients had positive lymph nodes, all had teratoma germ cell tumor. Ten patients had only necrosis in lymph nodes. After median follow-up 23 months (range 3-58 months), no systemic or retroperitoneal recurrence was found. Four patients developed chyle leak. One patient was managed conservatively with diet modification, one with intranodal lipiodol lymphangiography and two patients were managed surgically. CONCLUSION: RA-RPLND is safe and feasible for postchemotherapy residual mass with accepted compilation rate, but larger studies are required to establish its diagnostic and therapeutic utility along with safety of the procedure.

Salvage Strategies for Management of Testicular Tumors.

Testicular germ cell tumors (GCTs) comprise 2% of all human male malignancies and are the most common solid tumors in men between ages 15 and 35 years. Risk of contralateral testicular GCT is between 1 and 5%. Partial orchidectomy (PO) was originally described in 1984 by Richie. The evolving indications include metachronous tumors and tumor in solitary testicles. Also, small non-palpable lesions detected only by ultrasonography (USG) in asymptomatic patients is another indication. Salvagability is only chosen for tumors less than 2 cm in size. The key feature of PO is an inguinal approach with early vascular control using a rubber tourniquet before testicular mobilization into the field to avoid systemic tumor seeding. After, mass excision with a margin mandatory frozen section is done to assess adequacy of resection. Intra-op USG may be beneficial in small non-palpable lesions. Post op tumor markers are assessed and patients are taught self-examination of testis. Recent series shows that PO is safe and gives adequate oncological control. Carcinoma in situ (CIS) in the affected testis at PO or after testicular sparing surgery remains a challenge. At most centers, 20 Gy is recommended when adjuvant local radiation treatment is chosen to treat CIS. But this dose may hamper Androgen production. Radical orchiectomy remains the gold standard and should be discussed as part of informed consent. It is mandatory to highlight the risks of local recurrence and CIS, and treatment (observation, radiation, or completion orchiectomy) as well as the need for androgen supplementation and fertility risks before choosing testicular salvage procedures.

Role of regional anesthesia for placement of peritoneal dialysis catheter under ultrasound guidance: Our experience with 52 end-stage renal disease patients.

AIM: The number of patients with end-stage renal disease (ESRD) has shown a consistent rise in India in recent years. Continuous ambulatory peritoneal dialysis (CAPD) remains one of the safe and effective forms of treatment. In this study, we have tried to assess the effectiveness of field block technique for analgesia during catheter placement surgery until 24 h postoperatively, also, if it can obviate the need for general anesthesia in these high-risk patients. MATERIALS AND METHODS: We studied 52 ESRD patients from 2010 to 2012 who were posted for CAPD catheterization in the Department of Urology, Care Hospital, Hyderabad, India. Under ultrasound guidance, "unilateral posterior" and "unilateral subcostal" transversus abdominis plane block anesthesia were given for the placement of CAPD catheter. Patient's intra-operative pain and post-operative pain were recorded with visual analog scores (VAS) and analyzed. RESULTS: All patients in our study belonged to American Society of Anesthesiologists category 2 or 3 with multiple co-morbidities. 41 out of 52 patients required no supplemental analgesia during the procedure; 8 patients needed additional infiltration of local anesthetic during skin incisions. Three patients required supplemental analgesia and were considered as failure. A VAS of two was noted in 30 patients and 1 in 19 Patients. No Patient had significant pain 24 h post operatively. No local complication was noted in any patient. CONCLUSION: CAPD Catheterization under regional field block remains safe and effective options for ESRD patients.