[Interest of surgical companionship during the training period of robot-assisted radical prostatectomy]. / Intérêt du compagnonnage chirurgical durant la période d'apprentissage de la prostatectomie radicale robot-assistée.

OBJECTIVE: Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification. PATIENTS AND METHODS: Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group. RESULTS: Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3. CONCLUSION: The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair. LEVEL OF EVIDENCE: 4.

Anatomic feasibility of a new endopelvic approach for iliac crest bone harvesting.

PURPOSE: For the past few years, anterior exposure for surgery of the lumbar spine has gained popularity for the treatment of disk disease or spondylosis. Cancellous bone remains the gold standard for fusion. Iliac crest bone harvesting is safe but there are donor site complications. Bone substitutes exist, like recombinant human bone morphogenic protein-2 rhBMP-2. This alternative offers a high rate of fusion but with local and general complications. The aim of our study is to show the feasibility of an endopelvic approach for iliac bone crest harvesting to avoid donor site complication. METHOD: Twenty anterior retroperitoneal lumbar spine approaches have been realized in the anatomy department of the University of Bordeaux. The volumes of cancellous bone have been measured and procedure complications have been reported. RESULTS: The mean volume of cancellous bone was 5.9 cc, the maximum volume was 8.2 cc and the minimum volume was 4.5 cc. No complications have been reported during the approach or the bone harvesting. CONCLUSIONS: Anterior retroperitoneal approach for iliac bone crest harvesting is a safe way to obtain sufficient volume of cancellous bone for a single lumbar spinal fusion. This exposure avoids the risks of an iliac crest donor site complications or rhBMP-2 complications.

Use of Intercostal Flap for Conservative Surgical Management of Complex Lower Esophageal Fistula.

Lower esophageal fistula is a rare complication after upper digestive tract surgery, but it is associated with high morbi-mortality. There is no consensus on therapeutic care, however when reoperation is necessary, a pedicled inter-costal flap from the thoracotomy can be easily harvested to patch a large defect or buttress a direct suture, saving -digestive reconstruction. This technique should be mastered by thoracic and general surgeons. We present here two cases of lower esophagus fistulas cured thanks to this intercostal flap, in which we avoided fistula recurrence with maintenance of digestive continuity.