Robotic surgery in public hospitals of Latin-America: a castle of sand?

INTRODUCTION: There is no information about the evolution of robotic programs in public hospitals of Latin-America. OBJECTIVE: To describe the current status and functioning of robotic programs in Latin-American public hospitals since their beginning to date. METHODS: We conducted a survey among leading urologists working at public hospitals of Latin-America who had acquired the Da Vinci laparoscopic-assisted robotic system. Questions included: date the program started, its utilization by other services, number and kind of surgeries, surgery paying system, surgery related deaths, occurrence and reasons of robotic program interruptions and its use for training purposes. Medians and 25-75 centiles (IQR) were estimated. RESULTS: Since 2009, there are ten public hospitals of four Latin-American countries that acquired the Da Vinci robotic system. The median number of months robotic programs has been functioning without considering transitory interruption: 43 (IQR 35, 55). Median number of urologic and total surgeries performed: 140 (IQR 94, 168) and 336 (IQR 292, 621), respectively. The corresponding median number of urologic and total surgeries performed per month: 3 (IQR 2, 5) and 8 (IQR 5, 11). Median number of total surgeries performed per year per institution was 94 (IQR 68,123). The median proportion of urologic cases was 40% (IQR 31, 48), ranging from 24 to 66%. Five of ten institutions had their urology programs transitory or definitively closed due to the high burden costs. CONCLUSION: Adoption and development of robotic surgery in some public hospitals of Latin-America have been hindered by high costs.

Robotic adenomectomy using a laparoscopic dissector.

INTRODUCTION: Only few reports are known about the use of robotic surgery for prostate benign enlargement. The robotic surgery can be improved by laparoscopic tricks. We show a video of robotic adenomectomy where a laparoscopic dissector is used to help create the plan between prostatic capsule and adenoma. MATERIALS AND METHODS: A 62 years old male had severe urinary flow outlet obstruction. Medical therapy was not effective. Ultrasound detected a 92gr enlarged prostate with a large middle lobe. Robotic assisted adenomectomy was scheduled. The procedure followed this sequence: opening of Retzius space, superficial suture of the Dorsal vein complex, horizontal cistotomy. The plan was created with electrocautery and blunt dissection with the laparoscopic dissector. Haemostatic sutures were placed between prostate fossa and the posterior bladder neck and closure of the cistotomy. RESULTS: Whole operation time was 160 minutes, with a blood loss of 80cc. There was no perioperative or post-operative complication. Catheter was removed after 4 days. Post-operatory uroflowmetry shows a peak flow of 30ml/sec. Pathological examination is negative for tumor. After 60 days IPSS was 8. CONCLUSION: Robotic prostate adenomectomy using the laparoscopic dissector is a safe and effective minimally invasive treatment for benign prostatic enlargement. It is a novel technique to find and dissect the plane between prostatic adenoma and capsule. This could be one more use of laparoscopic technology to improve surgical outcomes in robotic field.

Penile primary melanoma: analysis of 6 patients treated at Brazilian National Cancer Institute in the last eight years.

PURPOSE: To describe our experience in treating penile melanoma in 06 patients followed at our institution. MATERIALS AND METHODS: Between 2004 and 2012 six consecutive patients with penile melanoma were treated at our Institution. Stage of the disease was classified according to the 2002 AJCC pathologic system. Melanoma in situ (TIS) was diagnosed in one patient. One patient was staged as T1b, two patients as T2b and two patients as T4b. The clinical and pathological findings were evaluated. Immunohistochemical tests were performed for Melan-A, HNB-45, S-100 and C-KIT. All histological specimens were examined by the same pathologist (ABSS). The patients with Cis, stages T1b and one patient T2b underwent only local excision. One patient T2b underwent local excision and sentinel lymph node dissection. Two patients with melanoma stage T4b underwent partial penile amputation. One of these last patients had palpable inguinal lymph nodes at diagnosis and underwent bilateral inguinal lymphadenectomy and received systemic chemotherapy (dacarbazine, 30 cycles). RESULTS: Mean follow-up was 36.3 months. One patient, with stage T2b, died after 12 months due to disease recurrence with bilateral inguinal involvement. The patient who underwent chemotherapy progressed with lung metastases and died after 14 months of follow up. The disease-free survival at five years was 33.3%. CONCLUSION: Penile melanoma is a disease with poor prognosis in most cases. Local excision or partial penile amputation may have effective control for stages T1 and T2 lesions. Patients who have clinically proven metastases died despite surgical and adjuvant chemotherapy.

Analysis of the Learning Curve of Surgeons without Previous Experience in Laparoscopy to Perform Robot-Assisted Radical Prostatectomy.

OBJECTIVE: To assess the learning curve in robot-assisted radical prostatectomy (RARP) performed by surgeons without previous experience in laparoscopic prostatectomy. MATERIALS AND METHODS: We analyzed 119 patients submitted to RARP performed by two surgeons without previous experience in laparoscopic prostatectomy, with emphasis on the relevant outcomes such as continence, erectile function, and oncologic control with a minimum follow-up of 24 months. We used Fisher's exact test and the chi-square test to investigate the existence of a relationship between the variables and analysis of variance (ANOVA) to verify possible statistically significant differences between groups, at the 5% level. RESULTS: The patients' age varied from 41 to 72 years (mean = 61.09), with 68 (57.14%) cases having intermediate or high risk. There was a consistent decline in operative time. Of the 119 patients, 80.67% were continent 6 months after surgery and 89.07% 12 months afterward, while 35.29% were potent 6 months after surgery and 60.50% 12 months following surgery. Twelve months after surgery, the trifecta outcome rate was 51.26% and the pentafecta rate was 31.09%. There was progressive postoperative improvement and maintenance of continence and sexual potency until the last patient was operated in our sample. CONCLUSIONS: Robot-assisted radical prostatectomy does not require previous experience in laparoscopic radical prostatectomy, but the learning curve is not short to achieve the plateau.

Is previous experience in laparoscopic necessary to perform robotic radical prostatectomy? A comparative study with robotic and the classic open procedure in patients with prostate cancer.

PURPOSE: To assess comparative results of robot-assisted radical laparoscopic prostatectomy (RARP) performed by surgeons without any experience in laparoscopic prostatectomy and the open procedure performed by surgeons with large experience. METHODS: We analyzed 84 patients (50 subjected to robotic surgery) from June 2012 to September 2013. Data were prospectively collected in a customized database. Two surgeons carried out all the RARP cases. These two surgeons and six more performed the open cases. The perioperative outcomes between the two groups were analyzed with a minimum followup of 12 months. RESULTS: The corporal mass index (BMI) was higher in the open group (p=0.001). There was more operatve time, less hospitalization and blood loss, better trifecta and pentafecta and earlier continence (p=0.045) in the robotic group (p=0.001). There was no difference in positive surgical margins but with greater extraprostatic extension in the open group (p=0.002). CONCLUSIONS: Robot-assisted radical prostatectomy is a safe procedure even in the hands of surgeons with no previous experience. Besides this, better operative outcomes can be reached with this modern approach.

[Merkel cell carcinoma of penis]. / Carcinome du pénis à cellules de Merkel.

We describe the second case in literature of Merkel cell carcinoma of penis, a rare, very aggressive neuroendocrine tumor. Treatment is debatable in view of the fact that this kind of tumor has unpredictable biological behaviour, early regional lymph node involvement, early distant metastases and a high recurrence rate. Considering these facts, we used pre-operative lymphoscintigraphy, intra-operative lymph node mapping and sentinel node biopsy before performing a bilateral inguinal lymphadenectomy. All lymph nodes removed from each inguinal region were cancer-free. Although the patient had received a cycle of adjuvant chemotherapy he developed inguinal recurrence and iliac metastasis.

Is previous experience in laparoscopic necessary to perform robotic radical prostatectomy? A comparative study with robotic and the classic open procedure in patients with prostate cancer

PURPOSE: To assess comparative results of robot-assisted radical laparoscopic prostatectomy (RARP) performed by surgeons without any experience in laparoscopic prostatectomy and the open procedure performed by surgeons with large experience. METHODS: We analyzed 84 patients (50 subjected to robotic surgery) from June 2012 to September 2013. Data were prospectively collected in a customized database. Two surgeons carried out all the RARP cases. These two surgeons and six more performed the open cases. The perioperative outcomes between the two groups were analyzed with a minimum followup of 12 months. RESULTS: The corporal mass index (BMI) was higher in the open group (p=0.001). There was more operatve time, less hospitalization and blood loss, better trifecta and pentafecta and earlier continence (p=0.045) in the robotic group (p=0.001). There was no difference in positive surgical margins but with greater extraprostatic extension in the open group (p=0.002). CONCLUSIONS: Robot-assisted radical prostatectomy is a safe procedure even in the hands of surgeons with no previous experience. Besides this, better operative outcomes can be reached with this modern approach. .

Penile primary melanoma: analysis of 6 patients treated at Brazilian national cancer institute in the last eight years

Purpose To describe our experience in treating penile melanoma in 06 patients followed at our institution. Materials and Methods Between 2004 and 2012 six consecutive patients with penile melanoma were treated at our Institution. Stage of the disease was classified according to the 2002 AJCC pathologic system. Melanoma in situ (TIS) was diagnosed in one patient. One patient was staged as T1b, two patients as T2b and two patients as T4b. The clinical and pathological findings were evaluated. Immunohistochemical tests were performed for Melan-A, HNB-45, S-100 and C-KIT. All histological specimens were examined by the same pathologist (ABSS). The patients with Cis, stages T1b and one patient T2b underwent only local excision. One patient T2b underwent local excision and sentinel lymph node dissection. Two patients with melanoma stage T4b underwent partial penile amputation. One of these last patients had palpable inguinal lymph nodes at diagnosis and underwent bilateral inguinal lymphadenectomy and received systemic chemotherapy (dacarbazine, 30 cycles). Results Mean follow-up was 36.3 months. One patient, with stage T2b, died after 12 months due to disease recurrence with bilateral inguinal involvement. The patient who underwent chemotherapy progressed with lung metastases and died after 14 months of follow up. The disease-free survival at five years was 33.3%. Conclusion: Penile melanoma is a disease with poor prognosis in most cases. Local excision or partial penile amputation may have effective control for stages T1 and T2 lesions. Patients who have clinically proven metastases died despite surgical and adjuvant chemotherapy. .

Traumatic rupture of adrenal pseudocyst leading to massive hemorrhage in retroperitoneum.

We present the case of a patient who had a large pseudocyst in the right adrenal gland, which was ruptured following blunt abdominal trauma, leading to a voluminous hemorrhage in retroperitoneum. A 29-year old female patient was admitted in the emergency room following a fall from stairs with trauma in right flank. She underwent a computerized tomography that evidenced a large retroperitoneal collection, with no apparent renal damage. She was submitted to surgery, where a large ruptured cyst was observed, originating from the upper portion of the right adrenal gland. Cystic diseases of adrenal gland are rare. Highly voluminous cysts can be damaged in cases of blunt trauma to the lumbar region leading to large hematomas in retroperitoneum.