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Objectives: To highlight critical preoperative and intraoperative considerations in approaching fistula repair robotically. Methods: A search of the literature was conducted to identify relevant articles pertaining to robotic management of urinary fistulae. Results: Fistulae of the genitourinary tract can be a challenging dilemma for urologists, as definitive management may require surgical intervention. Pathogenesis of both enteric and non-enteric fistulae are multifactorial, and successful repair hinges on the meticulous perioperative evaluation, planning, and execution. Traditional open techniques can subject patients to increased morbidity and prolonged hospitalizations. Since its introduction, the robotic surgical platform has continued to expand its indications. Its three-dimensional visualization and tremor free wristed instrument movements have made the robotic platform an attractive option for genitourinary fistula reconstruction. Conclusion: Robotic management of complex urinary fistulae is feasible in expert hands; more studies are needed to define its role in the treatment algorithm of this devastating conditions.
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PURPOSE: This cross-sectional study assessed a generative-AI platform to automate the creation of accurate, appropriate, and compelling social-media (SoMe) posts from urological journal articles. MATERIALS AND METHODS: One hundred SoMe-posts from the top 3 journals in urology X (Twitter) profiles were collected from Aug-2022 to Oct-2023 A freeware GPT-tool was developed to auto-generate SoMe posts, which included title-summarization, key findings, pertinent emojis, hashtags, and DOI links to the article. Three physicians independently evaluated GPT-generated posts for achieving tetrafecta of accuracy and appropriateness criteria. Fifteen scenarios were created from 5 randomly selected posts from each journal. Each scenario contained both the original and the GPT-generated post for the same article. Five questions were formulated to investigate the posts' likability, shareability, engagement, understandability, and comprehensiveness. The paired posts were then randomized and presented to blinded academic authors and general public through Amazon Mechanical Turk (AMT) responders for preference evaluation. RESULTS: Median (IQR) time for post auto-generation was 10.2 seconds (8.5-12.5). Of the 150 rated GPT-generated posts, 115 (76.6%) met the correctness tetrafecta: 144 (96%) accurately summarized the title, 147 (98%) accurately presented the articles' main findings, 131 (87.3%) appropriately used emojis and hashtags 138 (92%). A total of 258 academic urologists and 493 AMT responders answered the surveys, wherein the GPT-generated posts consistently outperformed the original journals' posts for both academicians and AMT responders (P < .05). CONCLUSIONS: Generative-AI can automate the creation of SoMe posts from urology journal abstracts that are both accurate and preferable by the academic community and general public.
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BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.
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Consenso , Técnica Delphi , Conducto Inguinal , Escisión del Ganglio Linfático , Melanoma , Neoplasias del Pene , Complicaciones Posoperatorias , Neoplasias de la Vulva , Humanos , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/métodos , Femenino , Masculino , Neoplasias del Pene/cirugía , Neoplasias del Pene/patología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Neoplasias de la Vulva/cirugía , Neoplasias de la Vulva/patología , Melanoma/cirugía , Melanoma/patología , Conducto Inguinal/cirugía , Encuestas y CuestionariosRESUMEN
BACKGROUND: Vesicourethral anastomosis stenosis (VUAS) refers to the diameter narrowing of a vesicourethral anastomosis (VUA). It is a known complication after radical prostatectomy that nowadays presents in less than 1% of these cases. When the lumen narrows sufficiently to impede urine flow, obstructive symptoms arise. While the incidence of VUAS used to be notably higher prior to the widespread use of the robotic approach, traditional procedures still fail in up to 42% of cases. Initial management typically involves endoscopic procedures, such as dilation, incision, or resection. If these approaches prove ineffective, VUA reconstruction is warranted. Following the resection of the unhealthy urethra, a potential drawback is the insufficient length of the healthy proximal urethral to reach the bladder without tension. In such cases, urinary diversion with an ileal conduit is an option. However, when the patient prefers to maintain an orthotopic urinary tract configuration, there is limited guidance in the literature regarding surgical techniques. OBJECTIVE: To outline the indications, describe the step-by-step technique, and evaluate the outcomes of transperineal urethral advancement to facilitate a tension-free VUA. MATERIALS: We first discuss the indications to identify which patients are candidates for this procedure. Then, a step-by-step description of the robotic VUA revision assisted by transperineal urethral mobilization is presented. Detailed steps and helpful hints are included. Finally, we outline the postoperative pathway and expected outcomes. RESULTS: This technique allows patients with VUAS to preserve the orthotopic configuration of the urinary tract when a tension-free anastomosis proves challenging. Although urinary incontinence is expected, an artificial urinary sphincter could be placed in the following months. CONCLUSION: The robotic management of complex vesicourethral anastomosis stenosis with transperineal urethral advancement is a feasible and safe procedure that requires the interdisciplinary management of robotic and reconstructive urologists.
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Procedimientos Quirúrgicos Robotizados , Uretra , Masculino , Humanos , Uretra/cirugía , Constricción Patológica/etiología , Constricción Patológica/cirugía , Procedimientos Quirúrgicos Urogenitales , Anastomosis QuirúrgicaRESUMEN
ABSTRACT Objective: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). Materials and Methods: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. Results: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. Conclusion: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.
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The objective of this study was to compare transperineal (TP) versus transrectal (TR) magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) fusion prostate biopsy (PBx). Consecutive men who underwent prostate MRI followed by a systematic biopsy. Additional target biopsies were performed from Prostate Imaging Reporting & Data System (PIRADS) 3-5 lesions. Men who underwent TP PBx were matched 1:2 with a synchronous cohort undergoing TR PBx by PSA, Prostate volume (PV) and PIRADS score. Endpoint of the study was the detection of clinically significant prostate cancer (CSPCa; Grade Group ≥ 2). Univariate and multivariable analyses were performed. Results were considered statistically significant if p < 0.05. Overall, 504 patients met the inclusion criteria. A total of 168 TP PBx were pair-matched to 336 TR PBx patients. Baseline demographics and imaging characteristics were similar between the groups. Per patient, the CSPCa detection was 2.1% vs 6.3% (p = 0.4) for PIRADS 1-2, and 59% vs 60% (p = 0.9) for PIRADS 3-5, on TP vs TR PBx, respectively. Per lesion, the CSPCa detection for PIRADS 3 (21% vs 16%; p = 0.4), PIRADS 4 (51% vs 44%; p = 0.8) and PIRADS 5 (76% vs 84%; p = 0.3) was similar for TP vs TR PBx, respectively. However, the TP PBx showed a longer maximum cancer core length (11 vs 9 mm; p = 0.02) and higher cancer core involvement (83% vs 65%; p < 0.001) than TR PBx. Independent predictors for CSPCa detection were age, PSA, PV, abnormal digital rectal examination findings, and PIRADS 3-5. Our study demonstrated transperineal MRI/TRUS fusion PBx provides similar CSPCa detection, with larger prostate cancer core length and percent of core involvement, than transrectal PBx.
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Próstata , Neoplasias de la Próstata , Masculino , Humanos , Próstata/diagnóstico por imagen , Antígeno Prostático Específico , Imagen por Resonancia Magnética , Biopsia Guiada por Imagen , Neoplasias de la Próstata/diagnóstico por imagen , Espectroscopía de Resonancia MagnéticaRESUMEN
OBJECTIVE: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). MATERIALS AND METHODS: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. RESULTS: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. CONCLUSION: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.
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Neoplasias del Pene , Cirugía Asistida por Video , Anciano , Humanos , Masculino , Persona de Mediana Edad , Conducto Inguinal/cirugía , Conducto Inguinal/patología , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/patología , Neoplasias del Pene/cirugía , Neoplasias del Pene/patología , Resultado del Tratamiento , Cirugía Asistida por Video/métodos , Estudios RetrospectivosRESUMEN
Importance: Live feedback in the operating room is essential in surgical training. Despite the role this feedback plays in developing surgical skills, an accepted methodology to characterize the salient features of feedback has not been defined. Objective: To quantify the intraoperative feedback provided to trainees during live surgical cases and propose a standardized deconstruction for feedback. Design, Setting, and Participants: In this qualitative study using a mixed methods analysis, surgeons at a single academic tertiary care hospital were audio and video recorded in the operating room from April to October 2022. Urological residents, fellows, and faculty attending surgeons involved in robotic teaching cases during which trainees had active control of the robotic console for at least some portion of a surgery were eligible to voluntarily participate. Feedback was time stamped and transcribed verbatim. An iterative coding process was performed using recordings and transcript data until recurring themes emerged. Exposure: Feedback in audiovisual recorded surgery. Main Outcomes and Measures: The primary outcomes were the reliability and generalizability of a feedback classification system in characterizing surgical feedback. Secondary outcomes included assessing the utility of our system. Results: In 29 surgical procedures that were recorded and analyzed, 4 attending surgeons, 6 minimally invasive surgery fellows, and 5 residents (postgraduate years, 3-5) were involved. For the reliability of the system, 3 trained raters achieved moderate to substantial interrater reliability in coding cases using 5 types of triggers, 6 types of feedback, and 9 types of responses (prevalence-adjusted and bias-adjusted κ range: a 0.56 [95% CI, 0.45-0.68] minimum for triggers to a 0.99 [95% CI, 0.97-1.00] maximum for feedback and responses). For the generalizability of the system, 6 types of surgical procedures and 3711 instances of feedback were analyzed and coded with types of triggers, feedback, and responses. Significant differences in triggers, feedback, and responses reflected surgeon experience level and surgical task being performed. For example, as a response, attending surgeons took over for safety concerns more often for fellows than residents (prevalence rate ratio [RR], 3.97 [95% CI, 3.12-4.82]; P = .002), and suturing involved more errors that triggered feedback than dissection (RR, 1.65 [95% CI, 1.03-3.33]; P = .007). For the utility of the system, different combinations of trainer feedback had associations with rates of different trainee responses. For example, technical feedback with a visual component was associated with an increased rate of trainee behavioral change or verbal acknowledgment responses (RR, 1.11 [95% CI, 1.03-1.20]; P = .02). Conclusions and Relevance: These findings suggest that identifying different types of triggers, feedback, and responses may be a feasible and reliable method for classifying surgical feedback across several robotic procedures. Outcomes suggest that a system that can be generalized across surgical specialties and for trainees of different experience levels may help galvanize novel surgical education strategies.
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Especialidades Quirúrgicas , Cirujanos , Humanos , Retroalimentación , Reproducibilidad de los Resultados , Recurrencia Local de Neoplasia , Cirujanos/educaciónRESUMEN
INTRODUCTION: The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. RESULTS: Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while 2 considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/nonself-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). CONCLUSION: Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs, further improving patient safety.
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Bibliometría , Complicaciones Intraoperatorias , Humanos , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/epidemiologíaRESUMEN
BACKGROUND: Simple prostatectomy has been established as a management option for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with glands larger than 80 cc.1 Robotic-assisted simple prostatectomy (RASP) has been established as a safe and effective management option. This has been reported in multiple studies comparing it with the open approach where no statistically significant differences in complication rates have been found.2 The intrafascial approach is intended to add multiple benefits, such as not requiring continuous bladder irrigation and resection of a larger percentage of the adenoma, potentially leading to a lower reoperation rate and diagnosis of prostate cancer in patients in which this was missed preoperatively.3 OBJECTIVE: To present the resection of a very large prostate can lead to significant intraoperative challenges. Therefore, we demosntrate our intrafascial robotic management of a 470g prostate. MATERIALS AND METHODS: A 56-year-old with LUTS (IPSS: 34) for over 6 years, complicated with multiple episodes of urinary retention. PSA: 20.6 ng/mL. MRI reported a 463 cc prostate volume without focal lesions. First, the retropubic space was developed. Cystotomy was performed at the anterior bladder neck. A plane between the prostatic capsule and the surrounding fascia was dissected while carefully preserving the neurovascular bundles. Due to its large size, the prostate was divided into segments to facilitate its extraction. Hemostatic control and vesicourethral anastomosis were performed. RESULTS: Discharged on postoperative day 1 with a Jackson-Pratt drain and Foley catheter removed on days 6 and 9, respectively. Pathology was negative for malignancy. Patient-reported improvement of LUTS (IPSS: 3) and preservation of erectile function (SHIM: 23) at the 3-month follow-up. CONCLUSION: The intrafascial technique can be useful in cases where a large-sized prostate hinders a transvesical approach. Additionally, it allows for an easier piecemeal of the gland. A larger series is needed to determine its potential benefits.
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Síntomas del Sistema Urinario Inferior , Hiperplasia Prostática , Procedimientos Quirúrgicos Robotizados , Masculino , Humanos , Persona de Mediana Edad , Próstata/patología , Procedimientos Quirúrgicos Robotizados/métodos , Hiperplasia Prostática/complicaciones , Hiperplasia Prostática/cirugía , Hiperplasia Prostática/patología , Vejiga Urinaria/patología , Prostatectomía/métodos , Síntomas del Sistema Urinario Inferior/cirugía , Síntomas del Sistema Urinario Inferior/complicaciones , Resultado del TratamientoRESUMEN
OBJECTIVE: To report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with vesicourethral anastomotic stricture (VUAS) after radical prostatectomy (RP). METHODS: Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent VUAS after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complications Panel Assessment and Recommendations. RESULTS: Four cases with a median age of 68.5 (63.3-72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3-453) minutes, 255 (175-262.5) mL, and 2.5 (2-3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6-10), 38 (32-43), and 30 (27-41) days, respectively. No postoperative complications were reported. The median follow-up time was 16.25 (12-26) months, and no fistula recurrence was shown. CONCLUSION: Robotic-assisted laparoscopic repair could represent an effective approach for the simultaneous repair of RVF with concomitant VUAS. More studies and management standardization are needed to assess the role of the robotic platform in the simultaneous repair of RVF with VUAS after radical prostatectomy.
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Procedimientos Quirúrgicos Robotizados , Fístula de la Vejiga Urinaria , Masculino , Humanos , Anciano , Procedimientos Quirúrgicos Robotizados/efectos adversos , Constricción Patológica/etiología , Constricción Patológica/cirugía , Estudios Retrospectivos , Anastomosis Quirúrgica/efectos adversos , Prostatectomía/efectos adversos , Prostatectomía/métodosAsunto(s)
Imagen por Resonancia Magnética Intervencional , Neoplasias de la Próstata , Masculino , Humanos , Próstata/diagnóstico por imagen , Próstata/patología , Anestesia Local , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Imagen por Resonancia Magnética/métodos , Biopsia , Ultrasonografía , Biopsia Guiada por Imagen/métodos , Ultrasonografía Intervencional/métodos , Imagen por Resonancia Magnética Intervencional/métodosRESUMEN
BACKGROUND: Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). OBJECTIVE: To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. SURGICAL PROCEDURE: ONI was identified during PLND and managed according to the type of nerve injury. RESULTS AND LIMITATIONS: The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. CONCLUSIONS: ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. PATIENT SUMMARY: We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.
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Lesiones por Aplastamiento , Laparoscopía , Traumatismos de los Nervios Periféricos , Procedimientos Quirúrgicos Robotizados , Humanos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Nervio Obturador/lesiones , Nervio Obturador/cirugía , Estudios Retrospectivos , Escisión del Ganglio Linfático/métodos , Traumatismos de los Nervios Periféricos/etiología , Lesiones por Aplastamiento/complicaciones , Lesiones por Aplastamiento/cirugía , Laparoscopía/efectos adversosRESUMEN
Injury to the superior mesenteric artery (SMA) is a rare, underreported, and potentially devastating complication. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. Three different instances of intraoperative injury to the SMA are described in an accompanying video. All three occurred when the SMA was misidentified as the left renal artery during left robotic radical nephrectomy. In the first case, the SMA was mistakenly identified as the renal artery, but after further dissection, the real renal artery was identified and SMA injury was prevented. In the second case, the SMA was clipped and the real left renal artery was subsequently identified, requiring clip removal. In the third case, the SMA was clipped and completely transected, requiring prompt repair by vascular surgery with a successful outcome. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. The proper anatomic recognition of the SMA may prevent its injury. Intraoperative SMA injury should be promptly identified and repaired to avoid its devastating consequences.
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BACKGROUND: Inguinal lymph node dissection (ILND) plays a crucial role in the oncological management of patients with melanoma, penile, and vulvar cancer. This study aims to systematically evaluate perioperative adverse events (AEs) in patients undergoing ILND and its reporting. METHODS: A systematic review was conducted according to PRISMA. PubMed, MEDLINE, Scopus, and Embase were queried to identify studies discussing perioperative AEs in patients with melanoma, penile, and vulvar cancer following ILND. RESULTS: Our search generated 3.469 publications, with 296 studies meeting the inclusion criteria. Details of 14.421 patients were analyzed. Of these studies, 58 (19.5%) described intraoperative AEs (iAEs) as an outcome of interest. Overall, 68 (2.9%) patients reported at least one iAE. Postoperative AEs were reported in 278 studies, combining data on 10.898 patients. Overall, 5.748 (52.7%) patients documented ≥1 postoperative AEs. The most reported ILND-related AEs were lymphatic AEs, with a total of 4.055 (38.8%) events. The pooled meta-analysis confirmed that high BMI (RR 1.09; p = 0.006), ≥1 comorbidities (RR 1.79; p = 0.01), and diabetes (RR 1.81; p = < 0.00001) are independent predictors for any AEs after ILND. When assessing the quality of the AEs reporting, we found 25% of studies reported at least 50% of the required criteria. CONCLUSION: ILND performed in melanoma, penile, and vulvar cancer patients is a morbid procedure. The quality of the AEs reporting is suboptimal. A more standardized AEs reporting system is needed to produce comparable data across studies for furthering the development of strategies to decrease AEs.
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Vasos Linfáticos , Melanoma , Neoplasias del Pene , Neoplasias de la Vulva , Masculino , Femenino , Humanos , Neoplasias del Pene/cirugía , Neoplasias del Pene/patología , Neoplasias de la Vulva/cirugía , Neoplasias de la Vulva/etiología , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/métodos , Melanoma/cirugía , Vasos Linfáticos/patologíaRESUMEN
Objective: The aim of this study is to report our experience in minimally invasive management of rectovesical fistulae (RVFs). Materials and Methods: Between 2004 and 2021, 24 patients who underwent minimally invasive RVF repair by a single surgeon at 3 international institutions were retrospectively reviewed. Baseline demographic characteristics and perioperative and postoperative variables were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Guidelines Panel Assessment and Recommendations. Fistula repair was defined as confirmation of fistula closure by imaging and complete resolution of fistula-related symptoms at the 12-month follow-up. Continuous variables are reported as medians and quartiles, whereas categorical variables are reported as frequencies and percentages. Results: Twenty-four patients with RVFs were treated: 22 males (91.7%) and 2 females with a median age of 66 (64.2-68) years. Twenty cases (83.3%) occurred postsurgery, three cases (12.5%) after surgery with combined radiotherapy, and one case (4.1%) after a combination of energy treatments. A robotic approach was performed in 19 patients (79%) and laparoscopic approach in 5 patients (21%). Ninety-six percent of patients had previous fecal diversions. No intraoperative complications were recorded. The median operative time was 180 (140-282) minutes, estimated blood loss was 50 (40-125) mL, and length of hospital stay was 2 (2-3) days. There were two Grade II complications and one Grade IIIb complication. All patients met criteria for repair. Conclusions: Minimally invasive management of RVFs is feasible. More studies are needed to assess the role of this approach among all RVF management options.
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Laparoscopía , Fístula Rectal , Robótica , Masculino , Femenino , Humanos , Anciano , Estudios Retrospectivos , Laparoscopía/métodos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Fístula Rectal/cirugía , Fístula Rectal/etiologíaRESUMEN
ABSTRACT Introduction: Upper tract urothelial carcinoma (UTUC) accounts for 5-10% of all urothelial tumors (1). Radical nephroureterectomy (RNU) remains the standard treatment for high, and low-grade UTUC (2). Although the open approach has been considered the gold standard, robotic techniques have shown comparable oncological outcomes with potential advantages in terms of peri-operative morbidity (3). Materials and Methods: We present a novel "Keyhole" technique for management of distal ureter and bladder cuff during robotic RNU. This technique allows the surgeon to directly visualize the ureteric orifices, delineate resection borders, and maintain oncologic principles of en-bloc excision without necessitating secondary cystotomy incision or concomitant endoscopic procedure. Descriptive demographic characteristics, surgical, pathological, and oncological outcomes were analyzed. Complications were reported using the Clavien-Dindo classification system. Results: Between 2015 and 2020, ten patients underwent robotic RNU with bladder cuff excision using the Keyhole technique (single-dock, single-position). Median age was 75 years. Eight patients underwent surgery for right-sided tumors. Median operative time, estimated blood loss, and length of hospital stay were 287 min, 100 mL, and 3 days, respectively. No intraoperative complications occurred, and one grade II complication occurred during the 90-day postoperative period. All patients had high-grade UTUC, being 90% pure urothelial. Bladder recurrences occurred in 30% of patients with an overall median follow-up of 11.2 months. Conclusions: Keyhole technique for the management of distal ureter and bladder cuff during RNU represents a feasible approach with minimal 90-day complications and low bladder recurrence rate at centers of experience.
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OBJECTIVE: To report our experience and outcomes in minimally invasive management of rectourethral fistula (RUF). METHODS: From 2004 to 2021, 15 patients who underwent minimally invasive RUF repair by a single surgeon at 2 international institutions were retrospectively reviewed. Baseline demographic characteristics, perioperative, and postoperative data were collected. Complications were reported using the modified Clavien-Dindo Classification System and the European Association of Urology Complication Panel Assesment and Recommendations. Success was defined as complete resolution of fistula-related symptoms at 12-month follow-up along with confirmation of fistula closure by imaging or cystoscopy. Categorical variables were presented as frequencies and percentages whereas continuous variables were reported as median and quartiles. RESULTS: Fifteen male patients with a median age of 71 (64-79.2) years were treated. Four cases (26.6%) occurred postsurgery, 8 cases (53.3%) occurred after energy treatments, and 3 cases (20%) after surgery combined with an energy treatment modality. A robotic and laparoscopic approach was performed in 9 (60%) and 6 (40%) patients, respectively. No intraoperative complications were reported. Median operative time was 264 (217.5-341) minutes, estimated blood loss was 175 (137.5-200) mL, and the length of hospital stay was 4 days. Nine postoperative complications were reported. All patients were followed-up for 12 months with no recurrence reported. All patients reached our criteria for successful RUF repair. CONCLUSIONS: Minimally invasive surgery could represent an efficient way to manage RUF in selected patients. More studies and treatment standardization are needed to assess the role of minimally invasive surgery in the management of RUF.
Asunto(s)
Fístula Rectal , Enfermedades Uretrales , Fístula Urinaria , Anciano , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Fístula Rectal/cirugía , Estudios Retrospectivos , Enfermedades Uretrales/cirugía , Fístula Urinaria/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Persona de Mediana EdadRESUMEN
INTRODUCTION: Upper tract urothelial carcinoma (UTUC) accounts for 5-10% of all urothelial tumors (1). Radical nephroureterectomy (RNU) remains the standard treatment for high, and low-grade UTUC (2). Although the open approach has been considered the gold standard, robotic techniques have shown comparable oncological outcomes with potential advantages in terms of peri-operative morbidity (3). MATERIALS AND METHODS: We present a novel "Keyhole" technique for management of distal ureter and bladder cuff during robotic RNU. This technique allows the surgeon to directly visualize the ureteric orifices, delineate resection borders, and maintain oncologic principles of en-bloc excision without necessitating secondary cystotomy incision or concomitant endoscopic procedure. Descriptive demographic characteristics, surgical, pathological, and oncological outcomes were analyzed. Complications were reported using the Clavien-Dindo classification system. RESULTS: Between 2015 and 2020, ten patients underwent robotic RNU with bladder cuff excision using the Keyhole technique (single-dock, single-position). Median age was 75 years. Eight patients underwent surgery for right-sided tumors. Median operative time, estimated blood loss, and length of hospital stay were 287 min, 100 mL, and 3 days, respectively. No intraoperative complications occurred, and one grade II complication occurred during the 90-day postoperative period. All patients had high-grade UTUC, being 90% pure urothelial. Bladder recurrences occurred in 30% of patients with an overall median follow-up of 11.2 months. CONCLUSIONS: Keyhole technique for the management of distal ureter and bladder cuff during RNU represents a feasible approach with minimal 90-day complications and low bladder recurrence rate at centers of experience.