Ureteroscopy vs laparoscopic ureterolithotomy for large proximal ureteric stone: a randomised trial.

OBJECTIVE: To compare the outcomes of retrograde flexible ureteroscopy (fURS) with retroperitoneal laparoscopic ureterolithotomy (RLU) for large proximal ureteric stones. PATIENTS AND METHODS: A prospective randomised trial was conducted from January 2018 through December 2022 including patients with impacted proximal ureteric stones of 15-25 mm. Patients underwent fURS or RLU. Primary outcome was the stone-free rate. Demographic data, stone features, and complications rates were also compared between groups. RESULTS: A total of 64 patients were enrolled, 32 in each group. The mean impacted stone time was similar between groups, as well as stone size (17 mm) and stone density (>1000 Hounsfield Units). The ureteric stone-free rates between the two groups (93.7% in fURS vs 96.8% in RLU; odds ratio [OR] 0.72, 95% confidence interval [CI] -1.72 to 3.17; P = 0.554), and overall success rates, which take into account residual fragments in the kidney (84.3% in fURS vs 93.7% in RLU; OR 1.02, 95% CI -0.69 to 2.74; P = 0.23), were similar. Operative time was also not statistically significantly different between groups (median 80 vs 82 min; P = 0.101). There was no difference in hospital length of stay. Retropulsion rate was higher with fURS (65.6% vs 3.1%; p < 0.001). Residual hydronephrosis (34.3% each group) and complication rates did no differ according to treatment. CONCLUSION: Flexible URS and RLU are both highly efficient and present low morbidity for large impacted proximal ureteric stone treatment. RLU is not superior to fURS.

Long-term efficacy of complete trigonal electrofulguration for women with recurrent urinary tract infections.

INTRODUCTION AND OBJECTIVE: Recurrent urinary tract infections (R-UTIs) have a negative impact on quality of life and contribute to antimicrobial resistance. Long-term antibiotic therapy is the main treatment alternative but, in some cases, this approach may not be accepted by the patient, is ineffective or poorly tolerated. In selected women, electrofulguration (EF) of trigonal lesions has been shown to reduce urinary tract infection (UTI) episodes. METHODS: Between August 2006 and December 2017, 73 women with R-UTI had their data collected prospectively and analyzed. We evaluated the rate of UTIs during the initial 2 years of follow-up after fulguration based on symptoms and a positive urine culture. All patients failed with multiple antibiotic courses and were offered endoscopic electrofulguration of the entire trigonal and bladder neck mucosa with a rollerball probe. We present our long-term results using a strategy of complete fulguration of the trigone in women with R-UTIs. RESULTS: The median age was 64 years (range: 17-76 years) and the median follow-up time after EF was 4.2 years (range: 2.5-14 years). Overall, 70 patients (96%) remained free of UTI episodes during the first year of follow-up, at 2 years of follow-up, 57, 53% remained infection-free. Currently, UTIs are typically sparse, mild, and caused by multisensitive bacteria. CONCLUSIONS: Complete trigonal and bladder neck mucosal fulguration promoted a significant reduction of UTI episodes during the first 2 years of follow-up. Prospective controlled studies are needed to determine the role of EF in women with R-UTI.

Laparoscopic Ureterocalicostomy Technique.

PURPOSE: Ureterocalicostomy is a technique that was first described by Neuwirt in 1948 (1) The laparoscopic access was initiated in 2003 by Cherullo et al. (2), following the established principles of open surgery. In 2004, Gill et al. had two patients with UPJO treated with laparoscopic ureterocalicostomy, with success (3). In 2014, Arap et. al. presented a case series with good results in adults and children in our service (4). There are factors that prepare the surgeon for an ureterocalicostomy, such as the renal cortex thickness, although the decision is mainly taken during the procedure (5). MATERIAL AND METHODS: A 24 years-old female patient with right lumbar pain was referred to our institution. She already had a right open pyeloplasty two years ago. The CT scan presented a right hydronephrotic kidney, DMSA scan with 30% of relative function and a DTPA scan with an obstructive pattern. RESULTS: A laparoscopic ureterocalicostomy was performed due to the intra-operative findings (inferior kidney pole thickness and challenging access to the uretero-pelvic junction). The overall time was 130 minutes with no complications. The patient was discharged in two days and the double J was withdrawn in four weeks. The CT scan within one year demonstrates a reduction of the hydronephrosis. She had no more lumbar pain. CONCLUSION: In complex cases, the laparoscopic ureterocalicostomy proves to be a safe and efficient procedure, with a free tension-free anastomosis and the advantages of the laparoscopic access.

Periprostatic innervation: New issues based on segmental analysis of 10 human cadaver pelvic blocs.

BACKGROUND: The exact paths of periprostatic nerves have been under debate over the last decades. In the present study, the topographic distribution of nerves around the prostate and their relative distances from the prostatic capsule were analyzed in male cadaver visceral blocs. METHODS: The pelvic organs from ten fresh male cadavers were removed and serial sectioned en bloc for histological investigation. The macroslices was divided into four sectors. Each sector was centrally covered with a raster dividing each sector in three subsectors numbered clockwise. The prostatic capsule was identified, and distances of 2.5 and 5 mm from the prostate were demarked with lines. We quantified the number of nerve fibers present in each subsector of each slide and recorded their position relative to the prostatic capsule. RESULTS: In general, the topographic analysis revealed that the majority of nerves were identified in sectors 4 through 9, corresponding to the posterolateral and posterior surfaces of the prostate gland. At the prostate base, the majority of nerves were found at the posterolateral and posterior surfaces of the gland. Within the mid-region of the prostate, the same topographic distribution pattern was observed, but the nerve fibers were closer to the prostatic capsule. At the apical region, the percentage of nerve fibers identified in the anterior region was higher, despite their major concetration in the posterior surface. The nerves identified at the apex were mainly located up to 2.5 mm from the prostate. This proximity to the prostate was specifically observed in the anterolateral and anterior sectors. In the craniocaudal sense, the percentage of nerves identified between 2.5 and 5 mm from the prostatic capsule remained constant. CONCLUSIONS: A significant number of nerve fibers were present in the anterior and anterolateral positions, especially at the apex. The anterior nerves were closer to the prostate. This proximity suggests that the anterior nerves may participate in local physiology and that the cavernous nerves are probably formed by the posterior nerve fibers. It is likely that the safe distance of 2.5 mm from all surfaces of the prostate may be related to cavernous fiber preservation.

The role of urinary KIM-1, NGAL, CA19-9 and ß2-microglobulin in the assessment of ureteropelvic junction obstruction in adults.

PURPOSE: The objective of this study is to evaluate the diagnostic properties of urinary biomarkers in adults with ureteropelvic junction obstruction: KIM-1, NGAL, CA19-9, and ß2-microglobulin. We also assessed urinary biomarker concentrations following pyeloplasty. MATERIAL AND METHODS: We prospectively studied adults from December 2013 to February 2015. We included 47 patients with a mean age of 38.6 ± 12.7 years. Each patient provided four samples of voided urine for biomarker measurement, one at pre-operative consultation and the others at 1, 3, and 6 months of post-operative follow-up. The control group consisted of 40 healthy individuals with no hydronephrosis on ultrasound evaluation. RESULTS: KIM-1 had an area under the curve of 0.79 (95% CI 0.70-0.89), NGAL 0.71 (95% CI 0.61-0.83), CA19-9 0.70 (95% CI 0.60-0.81), and ß2-microgloblin 0.61 (95% CI 0.50-0.73). KIM-1 was the most sensitive marker with a cut-off of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%), whereas CA19-9 was the most specific with a cut-off of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). Urinary concentrations of biomarkers decreased after pyeloplasty. CONCLUSIONS: The evaluation of urinary biomarkers is useful in adults undergoing pyeloplasty. KIM-1, NGAL, and CA19-9 were elevated and significantly decreased after surgery.

Laparoscopic radical prostatectomy: the learning curve of a low volume surgeon.

OBJECTIVE: Analyze the learning curve for laparoscopic radical prostatectomy in a low volume program. MATERIALS AND METHODS: A single surgeon operated on 165 patients. Patients were consecutively divided in 3 groups of 55 patients (groups A, B, and C). An enhancement of estimated blood loss, surgery length, and presence of a positive surgical margin were all considered as a function of surgeon's experience. RESULTS: Operative time was 267 minutes for group A, 230 minutes for group B, and 159 minutes for group C, and the operative time decreased over time, but a significant difference was present only between groups A and C (P < 0.001). Mean estimated blood loss was 328 mL, 254 mL, and 206 mL (P = 0.24). A conversion to open surgery was necessary in 4 patients in group A. Positive surgical margin rates were 29.1%, 21.8%, and 5.5% (P = 0.02). Eight patients in group A, 4 patients in group B, and one in group C had biochemical recurrence. CONCLUSION: Significantly less intraoperative complications were evident after the first 51 cases. All other parameters (blood loss, operative time, and positive surgical margins) significantly decreased and stabilized after 110 cases. Those outcomes were somehow similar to previous published series by high-volume centers.

INFLUENCE OF MINIMALLY INVASIVE LAPAROSCOPIC EXPERIENCE SKILLS ON ROBOTIC SURGERY DEXTERITY.

BACKGROUND: It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities. AIM: To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background. METHODS: Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill. RESULTS: Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition. CONCLUSION: Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

Minimally Invasive and Open Donor Nephrectomy: Lessons Learned From a French Multicenter Experience.

BACKGROUND: We evaluated different techniques of donor nephrectomy. METHODS: Outcomes of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted la`paroscopy [RAL]) were compared. RESULTS: A total of 264 nephrectomies were performed: 65 in the OS group, 65 in the SL group, 65 in the HAL group, and 69 in RAL group. Operative time was longer for the RAL group (P < .001) with a mean time of 202 minutes (RAL), 182 minutes (OS), 173 minutes (SL), and 157 minutes (HAL). Complications (P = .002) and consumption of morphine derivates (P = .31) were lower for the RAL group (P = .0002). The visual analog scale pain scores (P = .002), hospital stay (P = .023), and time to return to full activities (P = .79) were higher for OS. CONCLUSIONS: The 4 different nephrectomy surgical approaches had similar favorable results. The robot-assisted technique presented as an alternative option, with low incidence of complications, less pain, and results comparable to the other techniques.

Laparoscopic pyeloplasty as an alternative to nephrectomy in adults with poorly functioning kidneys due to ureteropelvic junction obstruction.

OBJECTIVES: To evaluate outcomes of laparoscopic pyeloplasty (LP) in adults with poorly functioning kidney due to ureteropelvic junction obstruction (UPJO). METHODS: A retrospective comparative analysis was performed between adult patients who underwent LP due to UPJO with differential renal function (DRF) ≤ 15% and DRF > 15%. LP success rate and complications were assessed. LP success was defined as symptoms improvement and DRF improvement or stabilization. DRF and estimated glomerular filtration rate (eGFR) were analyzed before and 12 months after surgery to evaluate renal function recovery. DRF was estimated using Tc-99 m DMSA renal scintigraphy. RESULTS: Among 121 LP performed in the study period at our institution, 15 and 42 were included in the DRF ≤ 15% and DRF > 15% groups, respectively. At a median follow-up of 17.8 months, all patients with DRF ≤ 15% reported symptoms improvement. LP success rate was 86.7% and 90.5% (p = 0.65) for patients with DRF ≤ 15% and DRF > 15%, respectively. There were no complications in the DRF ≤ 15% group, while there were three complications recorded in the DRF > 15% group (Clavien 2 and 3b). In the DRF ≤ 15% group, mean pre-operative and post-operative DRF was 9.5% ± 3.6 and 10.5% ± 7.8 (p = 0.49), respectively. Median pre-operative and post-operative eGFR was 68.5 ml/min and 79.8 ml/min (p = 0.93), respectively. Two patients had DRF improvement after LP. CONCLUSIONS: LP in adult patients with UPJO and poor function kidneys is an effective and safe procedure. DRF recovery is seen in a minority of the patients; however, LP is an alternative to nephrectomy.

Pyeloplasty in Adults With Ureteropelvic Junction Obstruction in Poorly Functioning Kidneys: A Systematic Review.

OBJECTIVES: To systematically summarize the available evidence concerning the impact of pyeloplasty on symptoms and differential renal function (DRF) in adults with unilateral UPJO in poorly functioning kidneys (PFK), and to identify potential predictors of kidney function recovery that could help clinicians select candidates for pyeloplasty. METHODS: A literature search (MEDLINE, Embase, Google Scholar, Scopus, ClinicalTrials.gov, and the WHO Clinical Trials Registry) and systematic review were performed up to September 2020 according to the PRISMA guidelines. PFK were defined as a baseline DRF ≤30% on renal scintigraphy. The primary endpoints were symptom relief and postoperative scintigraphic DRF. Predictors of kidney function recovery were evaluated and compared among studies. RESULTS: Nine studies comprising 731 patients met the inclusion criteria and were included for evidence synthesis. A DRF increase >5% occurred in 13.3%-53.8% of 160 patients with a pre- and postoperative renal scan. Symptoms improved in 73.3%-93.3% of 141 adults after pyeloplasty. Neither patient's age, baseline DFR, comorbidities, degree of hydronephrosis, kidney parenchymal thickness, nor kidney biopsy findings consistently predicted a significant DRF increase among 375 patients undergoing pyeloplasty. CONCLUSION: Based on a low level of evidence, pyeloplasty may relieve symptoms and stabilize kidney function in adults with UPJO in PFK. A significant number of patients showed a DRF increase >5%, yet no consistent predictor of kidney function recovery was identified. Until more evidence becomes available, pyeloplasty could be considered for selected cases after accounting for the risks of a failure requiring a future nephrectomy.

Extended Versus Limited Pelvic Lymph Node Dissection During Radical Prostatectomy for Intermediate- and High-risk Prostate Cancer: Early Oncological Outcomes from a Randomized Phase 3 Trial.

BACKGROUND: The role of extended pelvic lymph node dissection (EPLND) in the surgical management of prostate cancer (PCa) patients remains controversial, mainly because of a lack of randomized controlled trials (RCTs). OBJECTIVE: To determine whether EPLND has better oncological outcomes than limited PLND (LPLND. DESIGN, SETTING AND PARTICIPANTS: This was a prospective, single-center phase 3 trial in patients with intermediate- or high-risk clinically localized PCa. INTERVENTION: Randomization (1:1) to LPLND (obturator nodes) or EPLND (obturator, external iliac, internal iliac, common iliac, and presacral nodes) bilaterally. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was biochemical recurrence-free survival (BRFS). Secondary outcomes were metastasis-free survival (MFS), cancer-specific survival (CSS), and histopathological findings. The trial was designed to show a minimal 15% advantage in 5-yr BRFS by EPLND. RESULTS AND LIMITATIONS: In total, 300 patients were randomized from May 2012 to December 2016 (150 LPLND and 150 EPLND). The median BRFS was 61.4 mo in the LPLND group and not reached in the EPLND group (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.63-1.32; p = 0.6). Median MFS was not reached in either group (HR 0.57, 95% CI 0.17-1.8; p = 0.3). CSS data were not available because no patient died from PCa before the cutoff date. In exploratory subgroup analysis, patients with preoperative biopsy International Society of Urological Pathology (ISUP) grade groups 3-5 who were allocated to EPLND had better BRFS (HR 0.33, 95% CI 0.14-0.74, interaction p = 0.007). The short follow-up and surgeon heterogeneity are limitations to this study. CONCLUSION: This RCT confirms that EPLND provides better pathological staging, while differences in early oncological outcomes were not demonstrated. Our subgroup analysis suggests a potential BCRFS benefit in patients diagnosed with ISUP grade groups 3-5; however, these findings should be considered hypothesis-generating and further RCTs with larger cohorts and longer follow up are necessary to better define the role of EPLND during RP. PATIENT SUMMARY: In this study, we investigated early outcomes in prostate cancer patients undergoing prostatectomy according to the anatomic extent of lymph node resection. We found that extended removal of lymph nodes did not reduce biochemical recurrence of prostate cancer in the expected range.

Transperitoneal versus extraperitoneal laparoscopic radical prostatectomy during the learning curve: does the surgical approach affect the complication rate?

PURPOSE: To compare the perioperative complication rate obtained with the transperitoneal laparoscopic radical prostatectomy (TLRP) and with the extraperitoneal LRP (ELRP) during the learning curve (LC). MATERIALS AND METHODS: Data of the initial 40 TLRP (Group 1) were retrospectively compared with the initial 40 ELRP (Group 2). Each Group of patients was operated by two different surgeons. RESULTS: The overall surgical time (175 min x 267.6 min; p < 0.001) and estimated blood loss (177.5 mL x 292.4 mL; p < 0.001) were statistically better in the Group 1. Two intraoperative complications were observed in Group 1 (5%) represented by one case of bleeding and one case of rectal injury, whereas four complications (10%) were observed in Group 2, represented by two cases of bleeding, one bladder and one rectal injuries (p = 0.675). Open conversion occurred once in each Group (2.5%). Overall postoperative complications were similar (52.5% x 35%; p = 0.365). Major early postoperative complications occurred in three and in one case in Group 1 and 2, respectively. Group 1 had two peritonitis (fecal and urinary), leading to one death in this group. CONCLUSIONS: No statistical differences in overall complication rates were observed. The transperitoneal approach presented more serious complications during the early postoperative time and this fact is attributed to the potential chance of intraperitoneal peritonitis not observed with the extraperitoneal route.

Postoperative Renal Function in Patients Undergoing Unilateral Nephrectomy: Development of a Prediction Model Using Preoperative Risk Factors and 51Cr-EDTA Clearance.

Objectives: To analyze the preoperative variables associated to the postoperative glomerular filtration rate (GFR) outcomes after nephrectomy for benign and malignant conditions, measured by the reference isotopic technique 51Cr-ethylene diamine tetra-acetic (51Cr-EDTA) and to create a model to predict the short-term postoperative GFR. Secondary aim was to evaluate which of the common equations for GFR estimation (Cockcroft-Gault, Modification of Diet in Renal Disease [MDRD] or Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) has the best correlation with the 51Cr-EDTA. Methods: Patients undergoing unilateral nephrectomy from 2014 to 2018 were selected. Pre- and postoperative variables were prospectively collected. Univariate and multivariate analyses were done to identify independent risk factors associated with renal function outcomes and to create a model to predict the postoperative GFR. Correlation analyses were performed to evaluate the performance of various serum creatinine-based equations for GFR estimation compared with 51Cr-EDTA. Results: In total, 107 patients were evaluated. After univariate and multivariate analyses, older age (p = 0.008), higher split function of the operated kidney on dimercaptosuccinic acid (DMSA) scintigraphy (p < 0.001), and lower preoperative 51Cr-EDTA (p < 0.001) were independent risk factors for higher GFR decline. Correlation analyses showed that GFR estimated by CKD-EPI equation had the best concordance to GFR measured by 51Cr-EDTA. Conclusions: Based on our findings age, DMSA and lower preoperative 51Cr-EDTA are predictors of postoperative renal function after unilateral nephrectomy. For the assessment of estimated GFR, CKD-EPI equation appears to have the best concordance with 51Cr-EDTA.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era.

OBJECTIVE: To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure. METHODS: Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve. RESULTS: The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction. CONCLUSIONS: Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

Laparoscopic nephrectomy outside gerota fascia for management of inflammatory kidney.

BACKGROUND AND PURPOSE: A nonfunctioning inflammatory kidney is a challenging surgical condition for urologists. Some investigators recommend open surgery because of the surgical difficulties caused by the inflammatory process, whereas others try to apply the advantages of a "simple" non-hand-assisted laparoscopic approach. We report our experience with simple laparoscopic nephrectomy for inflammatory kidney management. PATIENTS AND METHODS: From July 2002 through December 2006, 50 pure laparoscopic nephrectomies were performed for inflammatory kidney (43 because of pyelonephritis, 5 for xanthogranulomatous pyelonephritis (XGP), and 2 for pyonephrosis). Histopathologic analysis was the criterion used for inflammatory kidney diagnosis. Pain or recurrent urinary tract infection associated with a nonfunctioning excluded kidney was the eligibility criterion for the procedure. Preoperatively, all patients underwent complete image and functional renal assessment. Morcellation was used to remove surgical specimens. Conversion index, surgical difficulties, operative time, and postoperative complications were evaluated. RESULTS: Conversion was performed in 14 of 50 (28%) patients, including two with XGP and one with pyonephrosis. Adhesions, vascular (two inferior vena cava) lesions, and intestinal lesions (two colon) were the main causes of conversion. Acute pancreatitis developed in one patient, and one patient had a wound infection. Reoperations were unnecessary, and no deaths occurred. CONCLUSION: Pure laparoscopic nephrectomy was successful in 72% of patients with inflammatory kidneys. The laparoscopic dissection was useful even in those cases converted to open surgery. This is a high-risk procedure, however, and both surgeon and patient must be aware of that before the decision is made for this approach.

Postgraduate course in minimally invasive urological surgery.

BACKGROUND: Minimally invasive surgeries are increasingly common as the first option for most urological diseases. However, laparoscopic techniques are difficult to master, especially for surgeons who were not trained during their residency programs. Therefore, postgraduate courses are important for such matters. This study aims to evaluate the results of postgraduate courses in minimally invasive urological surgery. METHODS: A specific questionnaire was used to evaluate the impact of the course on urologists' professional activities. The questionnaire also evaluated demographic data and previous surgical experience. The postgraduate course was divided into 10 monthly modules, each one with 36 hours of activities, from March to December. All students of the laparoscopic postgraduate course from the last five years were enrolled in the study. RESULTS: Forty-one students were included in the study. Thirty-nine students were male (95.1%), and the mean age was 39.5 years (range, 30-60 years). Students from all regions of the country were enrolled. Thirty (73.2%) students had minor laparoscopic experience. All students improved their laparoscopic skills and were able to include new procedures in their daily surgical practice. Eleven students (26.8%) had no laparoscopic experience, and all of them started to perform laparoscopic procedures. The median level of impact on professional life was 75 points (range, 0-100 points). CONCLUSIONS: The postgraduate course is an appropriate way to acquire urological laparoscopic skills. The annual course allowed improvement and initiation of laparoscopic procedures, which significantly impacted urologists' daily activities.

Laparoscopic Ureterocalicostomy Technique

ABSTRACT Purpose: Ureterocalicostomy is a technique that was first described by Neuwirt in 1948 (1) The laparoscopic access was initiated in 2003 by Cherullo et al. (2), following the established principles of open surgery. In 2004, Gill et al. had two patients with UPJO treated with laparoscopic ureterocalicostomy, with success (3). In 2014, Arap et. al. presented a case series with good results in adults and children in our service (4). There are factors that prepare the surgeon for an ureterocalicostomy, such as the renal cortex thickness, although the decision is mainly taken during the procedure (5). Material and Methods: A 24 years-old female patient with right lumbar pain was referred to our institution. She already had a right open pyeloplasty two years ago. The CT scan presented a right hydronephrotic kidney, DMSA scan with 30% of relative function and a DTPA scan with an obstructive pattern. Results: A laparoscopic ureterocalicostomy was performed due to the intra-operative findings (inferior kidney pole thickness and challenging access to the uretero-pelvic junction). The overall time was 130 minutes with no complications. The patient was discharged in two days and the double J was withdrawn in four weeks. The CT scan within one year demonstrates a reduction of the hydronephrosis. She had no more lumbar pain. Conclusion: In complex cases, the laparoscopic ureterocalicostomy proves to be a safe and efficient procedure, with a free tension-free anastomosis and the advantages of the laparoscopic access.

Influence of minimally invasive laparoscopic experience skills on robotic surgery dexterity / Influência da experiência da cirurgia laparoscópica na destreza da cirurgia robótica

ABSTRACT Background: It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities. Aim: To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background. Methods: Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill. Results: Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition. Conclusion: Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

RESUMO Racional: É incerto se há transferência natural de habilidades da cirurgia laparoscópica para a robótica. Objetivo: Avaliar o desempenho e aprendizado de tarefas em plataforma robótica simulada em indivíduos com diferentes conhecimentos em cirurgia. Método: Três grupos de indivíduos foram testados quanto à habilidade robótica: a) especialistas em cirurgia laparoscópica (n=6); b) especialista em cirurgia convencional (n=6); e c) indivíduos não médicos. A idade variou em todo grupo entre 40-50 anos. Cinco repetições de quatro tarefas simuladas foram realizadas: visão espacial, coordenação bimanual, coordenação mão-pé-olho e destreza manual. Resultados: Especialistas em cirurgia laparoscópica tiveram desempenho semelhante aos indivíduos não médicos e melhor que os especialistas em cirurgia convencional em três das quatro tarefas. Todos os grupos melhoraram desempenho com repetições . Conclusão: Especialistas em cirurgia laparoscópica desempenharam melhor que os outros grupos, mas quase igualitariamente aos indivíduos não médicos. Especialista em cirurgia convencional apresentaram os piores resultados. Todos os grupos melhoraram com as repetições.