Evaluation of the Versius Robotic System for Infant Surgery-A Study in Piglets of Less than 10 kg Body Weight.

BACKGROUND: We were able to demonstrate the feasibility of a new robotic system (Versius, CMR Surgical, Cambridge, UK) for procedures in small inanimate cavities. The aim of this consecutive study was to test the Versius® system for its feasibility, performance, and safety of robotic abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. METHODS: A total of 24 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 4 piglets with a mean age of 12 days and a mean body weight of 6.4 (7-7.5) kg. Additional urological procedures were performed after euthanasia of the piglet. The Versius® robotic system was used with 5 mm wristed instruments and a 10 mm 3D 0° or 30° camera. The setup consisted of the master console and three to four separate arms. The performance of the procedure, the size, position, and the distance between the ports, the external and internal collisions, and complications of the procedures were recorded and analyzed. RESULTS: We were able to perform all surgical procedures as planned. We encountered neither surgical nor robot-associated complications in the live model. Whereas all abdominal procedures could be performed successfully under general anesthesia, one piglet was euthanized early before the thoracic interventions, likely due to pulmonary inflammatory response. Technical limitations were based on the size of the camera (10 mm) being too large and the minimal insertion depth of the instruments for calibration of the fulcrum point. CONCLUSIONS: Robotic surgery on newborns and infants appears technically feasible with the Versius® system. Software adjustments for fulcrum point calibration need to be implemented by the manufacturer as a result of our study. To further evaluate the Versius® system, prospective trials are needed, comparing it to open and laparoscopic surgery as well as to other robotic systems.

Preputioplasty as a surgical alternative in treatment of phimosis.

Preputioplasty denotes various surgical techniques directed at resolving phimosis without the need for radical or partial circumcision. This narrative review summarizes the best-known surgical techniques of preputioplasty. A MEDLINE and EMBASE-based literature search of original manuscripts and case reports published in English has been carried out using the following key words: "circumcision", "partial circumcision", "phimosis", "paraphimosis", and "preputioplasty". Six different procedures are explored in more detail and illustrated. The complication rates of all surgical procedures presented here are reported to be low. In cases of medical (rather than cultural and religious) indications, foreskin-preserving procedures present useful alternatives to circumcision in the routine clinical practice of urologists and pediatric surgeons.

Identifying the Optimal Candidate for Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer: Results from a Large, Multi-institutional Analysis.

BACKGROUND: Salvage lymph node dissection (SLND) represents a possible treatment option for prostate cancer patients affected by nodal recurrence after local treatment. However, SLND may be associated with intra- and postoperative complications, and the oncological benefit may be limited to specific groups of patients. OBJECTIVE: To identify the optimal candidates for SLND based on preoperative characteristics. DESIGN, SETTING, AND PARTICIPANTS: The study included 654 patients who experienced prostate-specific antigen (PSA) rise and nodal recurrence after radical prostatectomy (RP) and underwent SLND at nine tertiary referral centers. Lymph node recurrence was documented by positron emission tomography/computed tomography (PET/CT) scan using either 11C-choline or 68Ga-labeled prostate-specific membrane antigen ligand. INTERVENTION: SLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The study outcome was early clinical recurrence (eCR) developed within 1 yr after SLND. Multivariable Cox regression analysis was used to develop a predictive model. Multivariable-derived coefficients were used to develop a novel risk calculator. Decision-curve analysis was used to evaluate the net benefit of the predictive model. RESULTS AND LIMITATIONS: Median follow-up was 30 (interquartile range, 16-50) mo among patients without clinical recurrence (CR), and 334 patients developed CR after SLND. In particular, eCR at 1 yr after SLND was observed in 150 patients, with a Kaplan-Meier probability of eCR equal to 25%. The development of eCR was significantly associated with an increased risk of cancer-specific mortality at 3 yr, being 20% versus 1.4% in patients with and without eCR, respectively (p<0.0001). At multivariable analysis, Gleason grade group 5 (hazard ratio [HR]: 2.04; p<0.0001), time from RP to PSA rising (HR: 0.99; p=0.025), hormonal therapy administration at PSA rising after RP (HR: 1.47; p=0.0005), retroperitoneal uptake at PET/CT scan (HR: 1.24; p=0.038), three or more positive spots at PET/CT scan (HR: 1.26; p=0.019), and PSA level at SLND (HR: 1.05; p<0.0001) were significant predictors of CR after SLND. The coefficients of the predictive model were used to develop a risk calculator for eCR at 1 yr after SLND. The discrimination of the model (Harrel'sC index) was 0.75. At decision-curve analysis, the net benefit of the model was higher than the "treat-all" option at all the threshold probabilities. CONCLUSIONS: We reported the largest available series of patients treated with SLND. Roughly 25% of men developed eCR after surgery. We developed the first risk stratification tool to identify the optimal candidate to SLND based on routinely available preoperative characteristics. This tool can be useful to avoid use of SLND in men more likely to progress despite any imaging-guided approach. PATIENT SUMMARY: The risk of early recurrence after salvage lymph node dissection (SLND) was approximately 25%. In this study, we developed a novel tool to predict the risk of early failure after SLND. This tool will be useful to identify patients who would benefit the most from SLND from other patients who should be spared from surgery.

Barry shunt for treatment of a 76-hour stuttering priapism without subsequent erectile dysfunction.

INTRODUCTION: This paper reports treatment of a 76-hour low-flow priapism with a shunting procedure that was first described by Barry in 1976. We were able to observe the preservation of erectile function despite the long period of ischemia. A review of the literature shows that there are few reports of erectile function recovery after a priapism of similar duration. MATERIALS AND METHODS: A 42-year-old patient presented with a 76-hour priapism, probably caused by consumption of alcohol and illegal drugs. A Barry Shunt procedure was performed. The erectile function of the patient was assessed by means of International Index of Erectile Function score over a follow-up period of 30 months. Moreover, we reviewed different surgical options for treatment of priapism in the literature. RESULTS: Partial return of erection without sexual arousal occurred on two occasions during the 10-day hospitalization, but was treated by manipulation of the penis, ie, by milking the tumescence into the shunt. After 3 months, the shunt was still palpable as a subcutaneous swelling. Six months postoperatively, the residual swelling had disappeared. The International Index of Erectile Function score was of 21 without phosphodiesterase type 5 inhibitors after a follow-up of 2.5 years. CONCLUSION: Barry shunt is an effective alternative surgical option for the treatment of low-flow priapism. In the case of our patient, it was also effective after a 76-hour-lasting priapism.

Sensitivity and specificity of PET/CT regarding the detection of lymph node metastases in prostate cancer recurrence.

BACKGROUND: The aim of the study is to assess the efficacy of choline PET/CT regarding the detection of lymph node (LN) metastases in recurrent prostate cancer (PCa). METHODS: 49 patients with a biochemical recurrence of PCa (PSA >0.2 ng/ml) were included in the study. All patients were selected for further diagnostics with a choline-PET/CT. All patients underwent salvage extended lymphadenectomy. The PET/CT result and the histological findings were analyzed regarding the specificity and sensitivity and with respect to the localization of the metastases. The detection rate of LN metastases was analyzed with respect to interdependencies between the pre-PET/CT PSA-value as well as the role of prior ADT. RESULTS: 41 out of 49 (83.6%) patients showed positive PET/CT results. Positive LNs were found in 27 out of 49 patients (55.1%). 48.9% of the PET-CT-findings proved true positive, 36.7% were found to be false positive. 8.1% proved true negative and 8.1% false negative. This results in a specificity of 22.7% and a sensitivity of 85.1%. Out of the true positive PET/CT scans, 61.9% were not congruent regarding the localization of positive LNs. In patients with PSA [greater than or equal to] 5 ng/ml, the sensitivity of the PET/CT result was 93.7%, while specificity was 0%. In 24 patients who underwent ADT prior to the PET/CT diagnostics, the sensitivity was 84.6% and specificity 9.0%. CONCLUSIONS: The reliability of PET/CT imaging for detection of LN metastases is limited by a high false-positive rate. The influence of ADT further diminishes the PET/CT reliability. Sensitivity of the PET/CT is highest in patients with a PSA of [greater than or equal to] 5 ng/ml. Based on our results, we propose the following conclusions: 1. There is no well-established diagnostic alternative to Choline-PET/CT Scan. Therefore this method may continue to be performed in patients with BCR. 2. It is not sufficient to remove only those LNs that show up in the PET/CT. 3. Salvage extended lymphadenectomy should follow a predefined template (e.g. the "Kiel template") and not just the PET/CT scan results.

Extended salvage pelvic lymph node dissection in patients with recurrent prostate cancer.

Background. Treatment of patients with a biochemical recurrence (BCR) of prostate cancer (PCa) is generally difficult and without valid treatment options. Since 2004 we have been developing therapeutic possibilities for these patients. Methods. We retrospectively analyzed a cohort of 41 patients with a BCR of PCa and a mean followup of 40.3 ± 20.8 months. Group 1 (n = 10): salvage radical prostatectomy (sRP) with SePLND (salvage extended pelvic lymph nodes dissection) (initial treatment: combined brachytherapy). Group 2 (n = 22): SePLND (initial treatment: radical prostatectomy (RP)). Group 3 (n = 9): SePLND (initial treatment: RP and adjuvant radiation therapy (RT)). We observed PSA, PSA-velocity, localization of LNs and LNs+, BCR-free period, and BR (biochemical response). Results. Group 1: 60% with BCR-freedom (mean 27.2 months). Group 2: 63.6% with BCR-freedom (mean 17.5 months). Group 3: 33.3% with BCR-freedom (mean 17.6 months). In total, BCR-freedom was observed in 23 of 41 patients (56.1%) after salvage surgery. 75.6% of all patients showed a BR. 765 LNs were removed and 14.8% of these were LN+. Conclusions. The BCR-free period and BR are comparable in all three groups. Sensibility to ADT can be reestablished and prolonged as a result of SePLND. Multicenter studies are needed for a reliable output.