Progressive perioperative benefits of laparoscopy in combination with an ERAS (Enhanced Recovery After Surgery) protocol in radical cystectomy with ileal conduit. / Beneficios perioperatorios progresivos de la laparoscopia y su combinación con un programa Enhanced recovery after surgery (ERAS) en la cistectomía radical con derivación urinaria heterotópica.

INTRODUCTION: Although in the recent years, laparoscopy and Enhanced Recovery After Surgery (ERAS) protocols have improved postoperative recovery in radical cystectomy (RC), the clinical efficacy of their association remains unclear. Our objective is to analyze the possible benefits obtained from laparoscopic RC (LRC) and its subsequent combination with an ERAS (ERAS-LRC) protocol compared to open RC (ORC). MATERIAL AND METHODS: We analyzed 187 consecutive RCs with ileal conduit performed in our center, of which 139 met the inclusion criteria: 47 ORC, 39 LRC (both with conventional protocol) and 52 ERAS-LRCs. RESULTS: No significant differences were found regarding age, sex, BMI and ASA score between groups. ERAS-LRC obtained a shorter length of stay than LRC and ORC (median 8 [7-10]) vs. 13 [10-17] vs. 15 [13-19.5] days, respectively; P<.001). ERAS-LRC had a shorter stay in the ICU and less days of nasogastric tube (P<.001). Postoperative complications and readmission rates were similar among groups. Multivariate logistic regression showed that absence of complications, younger age and ERAS behaved as independent factors for shorter hospital stay, while ERAS was the only independent factor of lower readmission rate at 90 days. CONCLUSIONS: Although LRC presented perioperative benefits compared to ORC, the results were better after the implementation of an ERAS protocol. ERAS protocol had stronger impact on recovery than the surgical approach of the procedure.

Live surgery: Safety study after 17 editions of retroperitoneoscopic surgery. / Cirugía en directo: estudio de seguridad tras 17 ediciones de cirugía retroperitoneoscópica.

INTRODUCTION: Live surgery has become an excellent tool for medical training. Despite this, there is controversy about the safety of the patients involved. OBJECTIVE: To analyze the results of live surgeries performed in 17 consecutive retroperitoneoscopy courses organized in our center. Procedures performed were partial nephrectomy (PN), radical nephrectomy (RN) and nephroureterectomy (NU). MATERIAL AND METHODS: Review from January 2010 to October 2017 of all live surgeries carried out by an expert surgical team in the retroperitoneoscopy courses, compared with a control group of surgeries performed in standard conditions. A matching (1:1 for each RN and 1:2 for each PN and NU) according to age, body mass index and comorbidities was performed. RESULTS: Twenty-one live surgeries were analyzed (eight PN, seven RN and six NU) with a global median follow-up of 38 months. No significant differences were observed between both groups in terms of perioperative variables (operative time, operative bleeding and intraoperative complications) or of postoperative complications and length of hospital stay. Likewise, there were no differences between recurrence rates (PN: 0% vs. 6.3%, p = 0.47, NU: 33.3% vs. 66.7%, p = 0.180, RN: 0% vs. 28.6%, p = 0,127). CONCLUSIONS: Live surgery in the hands of expert surgeons in a suitable environment and with well-selected patients does not increase the risk of complications and allows maintaining the same oncological outcomes.

Laparoscopic partial nephrectomy: Comparative study of the transperitoneal pathway and the retroperitoneal pathway. / Nefrectomía parcial laparoscópica: estudio comparativo entre la vía transperitoneal y la vía retroperitoneal.

INTRODUCTION: Laparoscopic partial nephrectomy is the recommended treatment for tumours smaller than 4cm in cases where it is feasible. Depending on the location of the tumour, the transabdominal or direct retroperitoneal pathway may be considered. OBJECTIVE: To compare the transperitoneal (TPPN) and direct retroperitoneal (RPPN) partial nephrectomies performed between 2007 and 2016. MATERIAL AND METHODS: A retrospective study was conducted on 71 patients who underwent TPPN (42) or direct RPPN (29) partial nephrectomy. We evaluated the characteristics of the patients and tumours, including tumour complexity (PADUA, RENAL, C-index). We compared perioperational variables, including the complications between the 2 pathways. RESULTS: We found no differences in terms of age, sex, Charlson's score and BMI. A larger proportion of patients in the direct RPPN group had prior major abdominal surgery (7.1 vs. 24.1%; P=.043). There were no differences in tumour size, laterality, polarity or complexity in any of the assessed scores. There were significant differences in tumour location (anterior/middle/posterior) between the TPPN and RPPN groups (54.8/31/14.3 vs. 3.4/13.8/82.8%; P<.001). There were no differences in the surgical time or length of stay. The TPPN group had a smaller urinary tract opening (4.8 vs. 27.6%; P=.007) and a higher percentage of haemostatic renorrhaphy (47.6 vs. 17.2%; P=.008). There were no differences in the need for warm ischaemia, in the changes in haemoglobin levels or in the glomerular filtration rate. The complication rates were similar for the two series. CONCLUSION: The two pathways show similar results in terms of renal function preservation, complications and oncological results. However, we recommend understanding both techniques and adapting the access type to the clinical case.

Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy.

BACKGROUND AND STUDY AIMS: Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy, but is usually mild and stops spontaneously. We report five cases of life-threatening hemorrhage following this procedure, which were treated successfully by endoscopic injection. PATIENTS AND METHODS: A total of 550 consecutive patients underwent TRUS-guided prostate biopsy in an outpatient setting. TRUS was performed using a Sonolayer 140 A (Toshiba) unit with a 7-MHz biplane transrectal probe, which was covered with two prophylactic sheaths. Sextant prostatic biopsies were systematically performed with a 16-gauge or 18-gauge needle without antibiotic prophylaxis. RESULTS: Five patients (1%) presented rectal bleeding with hypovolemic symptoms shortly after the procedure. Emergency colonoscopy revealed active bleeding from biopsy sites in the anterior rectal wall. Endoscopic injection of epinephrine and polidocanol achieved control of bleeding and permanent hemostasis in all cases. The patients required hospitalization and a mean of 4 packed red blood cell units (range 2-7). The patients were discharged, with uneventful recoveries. CONCLUSIONS: Colonoscopy should be carried out in patients presenting severe rectal bleeding after TRUS-guided prostate biopsy. Endoscopic treatment can be used to deal with this rare complication.