Identify risk factors for perioperative outcomes in Intracorporeal Urinary Diversion and Extracorporeal Urinary Diversion with Robotic Cystectomy.

INTRODUCTION: The increasing adoption of robotic-assisted cystectomy with intracorporeal urinary diversion (ICUD), despite its complexity, prompts a detailed comparison with extracorporeal urinary diversion (ECUD). Our study at a single institution investigates perioperative outcomes and identifies risk factors impacting the success of these surgical approaches. METHODS: In this retrospective analysis, 174 patients who underwent robotic-assisted cystectomy at the University of Louisville from June 2016 to August 2021 were reviewed. The cohort was divided into two groups based on the urinary diversion method: 30 patients underwent ECUD and 144 underwent ICUD. Data on demographics, complication rates, length of hospital stay, and readmission rates were meticulously collected and analyzed. RESULTS: Operative times were comparable between the ICUD and ECUD groups. However, the ICUD group had a significantly lower intraoperative transfusion rate (0.5 vs. 1.0, p=0.02) and shorter hospital stay (7.8 vs. 12.3 days, p<0.001). Factors such as male sex, smoking history, diabetes mellitus, intravesical therapy, higher ASA, and ACCI scores were associated with increased Clavien-Dindo Grade 3 or higher complications. Age over 70 was the sole factor linked to a higher 90-day readmission rate, with no specific characteristics influencing the 30-day rate. CONCLUSION: Robotic cystectomy with ICUD results in shorter hospitalizations and lower intraoperative transfusion rates compared to ECUD, without differences in operative time, high-grade postoperative complications, or readmission rates. These findings can inform clinical decision-making, highlighting ICUD as a potentially more favorable option in appropriate settings.

Long-term Urological Outcomes in Pelvic Genitourinary Rhabdomyosarcoma: A 48-Year Single-center Experience.

PURPOSE: Multimodal therapy has improved survival in genitourinary rhabdomyosarcoma, a rare pediatric cancer. However, little is reported regarding postoperative complications and long-term urinary and sexual function and quality of life. MATERIALS AND METHODS: We reviewed records from 1970-2018 to identify patients with genitourinary rhabdomyosarcoma of the bladder, prostate, pelvis, vagina, and uterus. We assessed modes of therapy, and if surgical, the type of resection, reconstruction, and reoperation. Primary outcomes included urinary continence, urinary tract infection occurrence, and stone formation. We also surveyed patients older than 18 years for urinary and sexual function. RESULTS: Fifty-one patients were identified for the post-treatment outcomes cohort. All received chemotherapy, 46 (90.2%) underwent surgery, and 34 (67%) received radiation. Twenty-nine patients (56.9%) received trimodal therapy, 17 (33.3%) received chemotherapy/surgery, and 5 (9.8%) received chemotherapy/radiation. Twenty-six had up-front radical surgery (with staged continence mechanism creation); these patients had higher rates of continence, similar rates of urinary tract infection, and higher rates of stone formation compared to those who were organ-spared. A third (4/12) of organ-spared patients underwent additional corrective surgery. Thirty patients with genitourinary rhabdomyosarcoma were surveyed and 14 responded to questionnaires. Overall, urinary complaints were mild, but both male and female respondents reported significant sexual dysfunction. CONCLUSIONS: Organ-sparing treatment was more likely to predispose patients to high rates of additional reconstructive surgery due to compromised urological function. In survey results, both men and women reported poor sexual function, but the majority of patients remained satisfied with their urinary function.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps.

BACKGROUND: Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging. METHODS: A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝). CONCLUSION: There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed. TRIAL REGISTRATION: PROSPERO (CRD42022353591).

Aesthetic Surgery Practice Resumption in the United Kingdom During the COVID-19 Pandemic.

BACKGROUND: The global COVID-19 pandemic has significantly impacted all aspects of healthcare, including the delivery of elective aesthetic surgery practice. A national, prospective data collection was carried out of the first aesthetic plastic surgery procedures performed during the COVID-19 pandemic in the United Kingdom. OBJECTIVES: The aim of this study was to explore the challenges aesthetic practice is facing and to identify if any problems or complications arose from carrying out aesthetic procedures during the COVID-19 pandemic. METHODS: Over a 6-week period from June 15 to August 2, 2020, data were collected by means of a proforma for aesthetic plastic surgery cases. All patients had outcomes recorded for an audit period of 14 days postsurgery. RESULTS: The results demonstrated that none of the 371 patients audited who underwent aesthetic surgical procedures developed any symptoms of COVID-19-related illness and none required treatment for any subsequent respiratory illness. CONCLUSIONS: No COVID-19-related cases or complications were found in a cohort of patients who underwent elective aesthetic procedures under strict screening and infection control protocols in the early resumption of elective service.

Secondary adenocarcinoma of the urinary bladder attributed to metastatic gastroesophageal cancer.

Metastases of advanced gastrointestinal malignancy to the bladder is a rare phenomenon. Few such cases have been reported. Here, we describe the case of a man with recurrent local gastroesophageal adenocarcinoma who presented with acute kidney injury and bilateral ureteral obstruction ultimately found to have de novo metastatic esophageal disease in the urinary bladder.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

BACKGROUND: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS: A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS: One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. CONCLUSION: Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.

Microsurgical Reconstruction of Large Oncologic Chest Wall Defects for Locally Advanced Breast Cancer or Osteoradionecrosis: A Retrospective Review of 26 Cases over a 5-Year Period.

BACKGROUND: Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled "unresectable." METHODS: We report a single-center experience with the microsurgical reconstruction of such defects over a 5-year period. Between 2007 and 2011, 1,077 microvascular reconstructive cases following breast cancer resection were performed, of which 26 cases comprised LABC or ORN requiring reconstruction. Surgical indications, defect parameters, choice of reconstruction, and outcomes were assessed. RESULTS: Thirty free flap microsurgical reconstructions were undertaken in 26 cases, with a 96.2% flap survival rate. Complications were low, and mean hospital stay was 8.7 days. An algorithmic approach to management is presented. CONCLUSION: Wide resection and microvascular free tissue transfer provide versatile solutions for the reconstruction of extensive chest wall defects. With good reported perioperative outcomes even in advanced cases, surgical resection of LABC may offer a useful approach in difficult and/or palliative cases.

Evaluation of a new skin closure device in surgical incisions associated with breast procedures.

BACKGROUND: A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner. To determine its clinical utility in breast procedures, a prospective clinical investigation was undertaken to demonstrate equivalence of a new adhesive (PRINEO™ Skin Closure System) to intradermal sutures in wound closure. METHODS: The investigation comprised 79 patients who underwent elective surgery for bilateral breast procedures. Each breast incision was randomized to wound closure with the PRINEO™ Skin Closure System or intradermal sutures (used in accordance with standard local practice). Postoperative evaluations took place at 24 hours, 7 days, 12-25 days, 90 days, 6 months, and 12 months. Data were collected on the continuous approximation of the skin edges, the time required to close the include final skin layer, the evaluation of incision healing, and cosmesis outcomes. Safety evaluations were related to the incidence and extent of local acute inflammatory reactions, clinical infection, skin blistering, and adverse events. RESULTS: PRINEO™ Skin Closure System was found to be equivalent to intradermal sutures for the continuous approximation of wounds associated with breast procedures. The upper limit of the one-sided 95% confidence interval for difference in proportions was less than the predetermined 12%, at 5.9%. The mean time to closure for the PRINEO™ Skin Closure System was 2.56 minutes, which was 13.66 minutes faster than that for intradermal sutures (16.22 minutes, P < 0.0001). Time savings may be less if 2 operators close simultaneously. On the other hand, because the device can be applied by 1 operator, the assistant's time may be freed up to attend to other tasks. Both treatments had similar incision healing and cosmetic outcomes. No quantitative or qualitative differences of clinical significance were evident between the treatment groups for local acute inflammatory reactions, clinical infection, or skin blistering. The number of serious adverse events was low, although the number of adverse events was higher, with 54/79 patients experiencing at least 1 adverse event. CONCLUSION: PRINEO™ Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions associated with breast procedures, with regard to safety and effectiveness. It was also 6.3 times faster than intradermal sutures for wound closure.

Transverse upper gracilis flap with implant in postmastectomy breast reconstruction: a case report.

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin-sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery.

Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken. Fluid input included crystalloids, colloids, or blood products. Fluid output included urine, blood, or suctioned fluid. Postoperative fluid balance was calculated as fluid input - output. Fluid input between groups was not different. Fluid output was greater in the ED group (P = 0.008). The ED group showed less fluid balance (P = 0.023), less anesthetic time (P = 0.001), less hospital stay (mean 1.9 days; P = 0.147), less monitoring and flap complications (P = 0.062). ED monitoring demonstrated no monitoring complications, provides a favorable postoperative fluid balance, and may reduce flap complications and hospital stay.

The extended diep flap: extending the possibilities for breast reconstruction with tissue from the lower abdomen.

BACKGROUND: The classical DIEP-flap is considered state-of-the-art in microsurgical autologous breast reconstruction. Some patients may require additional volume to match the contralateral breast. This quality control study prospectively evaluates the feasibility and outcome of a surgical technique, which pursues the volumetric augmentation of the DIEP-flap by harvesting of additional subscarpal fat tissue cranial to the classical flap border. PATIENTS AND METHODS: For radiologically based estimation of volumetric flap-gain potential, abdominal CT-scans of 10 Patients were randomly selected and used for computerized volumetric estimates. Surgical evaluation of the technique was prospectively performed between 09/2009 and 09/2010 in 10 patients undergoing breast reconstruction with extended DIEP-flap at two institutions. The outcome regarding size, volume, and symmetry was evaluated. RESULTS: Radiologically, the mean computed volume gain of an extended DIEP was 16.7%, when compared with the infraumbilical unilateral flap volume. Clinically, the intraoperatively measured mean volume gain was of 98.6 g (range: 75-121 g), representing 13.8% of the flap volume. All 10 flaps survived without revision surgery. In three flaps, minor fat necrosis occurred in zone III and was treated conservatively. No fat necrosis was observed in the extended flap area. CONCLUSIONS: In this first prospective series, the extended DIEP-flap proved to be feasible, reliable and safe for its use in breast reconstruction. Both radiological estimation and intraoperative measurements demonstrated a statistically significant volume gain with no complications in the extended area. The technique is of benefit in selected patients requiring additional reconstructive volume than the one achieved with the classical DIEP-flap. LEVEL OF EVIDENCE: Therapeutic Level IV.

Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps.

BACKGROUND: The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS: To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS: Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION: This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.

The thoracodorsal artery and vein as recipient vessels for microsurgical breast reconstruction.

Recipient vessels for microsurgical breast reconstructions include the internal mammary and thoracodorsal systems. This review will focus on the advantages of the thoracodorsal artery and vein.

Stacked TUG and DIEP flaps to reconstruct a single breast: Expanding the scope of autologous breast reconstruction.

When the entire abdominal tissue is inadequate to match the contralateral breast volume and shape or in bilateral cases, the deep inferior epigastric perforator (DIEP) flap alone might not be adequate, even if bipedicled. In such cases, using combinations of donor sites is useful and more effective. We present our series of breast reconstruction using stacked DIEP and transverse upper gracilis (TUG) flaps to achieve better breast volume and shape. Between 2015 and 2021, 7 patients underwent reconstruction with stacked flaps. Three surgical teams performed the surgery simultaneously. Flaps were stacked and shaped on a table; the DIEP was de-epithelised completely and placed upside down with the pedicle anteriorly. A cranial extension of the DIEP pedicle was anastomosed in series to the TUG vessels. The TUG was coned and placed above the DIEP, the skin paddle was used both to create a new nipple-areola complex and for monitoring. The stacked flaps were anastomosed to the recipient vessels and buried under the mastectomy flaps. No flap losses were encountered. The aesthetic outcome was good or excellent and patients considered the surgery as an improvement for their self-appearance. In patients with loose skin and minimal fat, or in bilateral reconstructions, the presented procedure can be considered as a reliable approach to obtain a better breast shape and simultaneously improve body contouring in the donor sites.

Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps.

INTRODUCTION: When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations. METHODS: Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average body mass index (BMI) was 23.1 kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. RESULTS: Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 h 50 min (195-460 min) and the mean combined flap weight was 551 g (279-916 g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n = 22), the flaps were oriented horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. CONCLUSIONS: Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

Development and In Vitro Assessment of a Novel Vacuum-Based Tissue-Holding Device for Laparoscopic and Robotic Kidney Cancer Operations.

In this paper, we describe the development and evaluation of a novel tissue-holding device (THD) for use during robotic-assisted laparoscopic partial nephrectomy. The THD is a vacuum-based apparatus made of either 3D-printed polyethylene or stainless steel. The proximal end connects to suction tubing routed outside the body, while the distal end is conically shaped and designed to firmly interface with the tumor. Device feasibility studies were performed on six porcine kidneys, two porcine livers, and two embalmed human cadavers. A Likert-scale rating was used to assess device setup, suction, and tissue handling. Additional tests were performed using the daVinci Xi® robotic system. Finally, the holding force of the THD was assessed using different standard vacuum systems and pressure settings. In porcine tissue, the device setup, tissue suction, and handling were rated as "good". THD insertion and removal was uncomplicated. In a simulated transabdominal approach on fixed human cadavers, the device setup, suction, and tissue handling were also rated as "good". No macroscopic tissue compromise or device deterioration was noted. The handling and holding abilities using the daVinci Xi® robotic system were also rated "good". The device was able to successfully hold over 300 g of tissue at a suction pressure of -600 mmHg. The preliminary evaluation of the THD demonstrated satisfactory results.