Videolaparoscopic prostatectomy in porcine model for training residents

ABSTRACT Introduction: Surgical training models prepare the resident for a more ethical surgical practice as well as providing a less steep learning curve. In urology, there are well-known models of pyeloplasty simulation, urethro-vesical anastomosis and nephrectomy, which have helped in the training of urology residents (1-3). Learning laparoscopic prostatectomy is a difficult surgery and requires advanced surgical skill from the surgeon (4), requires operate without a direct view of the surgical field in a two-dimensional space and with longer instruments (5). Laparoscopic prostatectomy step by step makes the surgeon's learning curve less difficult, lead to less intraoperative complications, such as blood loss, while also enabling shorter operative time and less positive surgical margins (6). The objective of surgical models is to simulate surgical procedures in a reliable way thus preparing the surgeon for his daily practice, surgical simulations in animal models have been described to compensate for inadequate clinical exposure (7). The canine model of prostate cancer has many similarities with humans. Despite trying to develop a model that is as credible as possible, there are ethical issues in several countries, such as Brazil, that do not allow the use of live dogs for scientific experimentation and there is a difficulty in not standardizing the animals used (8, 9). The swine surgical training model is widely known, accepted and used as a valuable tool in the teaching of new surgeons (10). The porcine video laparoscopic prostatectomy model allows the urologist in training to exercise the skills required in a real surgical situation, practicing them in a single session (10). We will present an experimental model in pigs for training urology residents in laparoscopic radical prostatectomy with current techniques (11-13). The limitations found are that the prostate has no limits as well defined as in humans, the urethra is long and coiled, the fat surrounding the pelvic organs is scarce and there is no postoperative follow-up for evaluating functionality after the procedure, as well as the effectiveness of the surgery with surgical margins. However, it is similar in surgical model presented, it is reproducible and can provide a realistic simulation environment to the beginner surgeon. Material and Methods: In this paper, according to the institutional protocol approved by the institutional ethics and research committee FMUSP n° 964/2017 and protocol was in accordance with current international regulations for the use of animals in Research: Reporting In Vivo Experiments (ARRIVE) guide. Ten male pigs weighing 20 to 22kg were used. The animals were anesthetized with a combination of Telazol (5mg/kg), Xylazine (1.5mg/kg), Cetamine (22mg/kg) and Atropine (0.04mg/kg) for orotracheal intubation followed by Isoflurane (2%). Animals were euthanized at the end of the procedure with a lethal dose of KCl (2mEq/kg). The trocar insertion points were marked using the epigastric vessels and umbilical region as reference points. Initially, urethral catheterization was performed using a hydrophilic Nitinol guidewire, followed by a perineal incision to dissect the tortuous urethra of the porcine model. A malleable urethral catheter 8Fr was inserted into their bladder. The animal was placed in the Trendelenburg position inserted and 12mm trocars were inserted in its umbilical region, utilizing 10mm in the surgeon's dominant hand, 5mm in his non-dominant hand of the surgeon, and 5mm in the first assistant's trocar. The surgeon replicates the steps performed in a laparoscopic radical prostatectomy in humans, including the bladder catheterization, dissection of the anterior bladder plane, the vesicular and prostatic dissection, the suture of the dorsal venous plexus, a prostatectomy, an urethral vesical anast omosis, as well as the waterproof test, even including the performing of surgical steps using current concepts of anterior urethral suspension as the reconstruction of the posterior plane of the rhabdosphincter. Results: All steps of surgery could be reproduced in all ten porcine cases. No significant bleeding was observed and the surgical time was gradually reduced fifty percent from case one to last cases. Conclusions: The porcine model allowed the surgeon to replicate all the steps usually performed in a laparoscopic radical prostatectomy. The junior surgeons are better prepared to such difficult surgery. However, further studies will be necessary to prove the impact of the animal model presented in urological clinical practice.

Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?

ABSTRACT Objective To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. Material and Methods Medical records of 82 consecutive children submitted to transperi-toneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. Results Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. Conclusions Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.

Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?

OBJECTIVE: To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. MATERIAL AND METHODS: Medical records of 82 consecutive children submitted to transperitoneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. RESULTS: Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. CONCLUSIONS: Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.

Step-by-step Laparoscopic Vesiculectomy for Hemospermia.

Hemospermia has been considered as a benign and self-limiting condition. It usually has an inflammatory or infectious cause. However, recurrent or persistent hemospermia may indicate a more serious underlying pathology, especially over 40 years of age. Biopsy or surgical excision is indicated in cases of suspicious findings during investigation, such as cysts or masses. Open surgery has been considered the definitive form of treatment, however, it can be associated with significant morbidity. With growing experience in laparoscopics, this approach is becoming the preferable way to access the seminal vesicles. Our objective is to demonstrate a step-by-step operative technique for laparoscopic unilateral vesiculectomy approach in a man with hemospermia. CASE: A 61 year-old man presented with 1 year of hemospermia. He was treated empirically with a fluoroquinolone plus a nonsteroidal anti-inflammatory without resolution of symptoms. Ultrasonography and MRI showed a solid-cystic mass in the right seminal vesicle. The patient was submitted to a laparoscopic unilateral vesiculectomy. Histopathological analysis showed intraluminal dilatation with blood content. During follow-up, complete resolution of symptoms was seen. RESULTS: Three patients composed our cohort. Mean age was 53 years-old (range 45-61 years), the right side was more commonly affected (two unilateral on the right and bilateral). Mean operative time was 55 minutes (range 40-120min). One patient presented amyloidosis in the histopathological analysis. All cases presented complete resolution of symptoms. CONCLUSIONS: Laparoscopic vesiculectomy is a safe and feasible approach in cases of hemospermia. This technique showed good outcomes and minimal morbidity.

Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique.

PURPOSE: Failure after pyeloplasty for ureteropelvic junction obstruction in children may occur in up to 10% of cases. Therapeutic options include Double-J® stent placement, endoscopic treatment and reoperation. Laparoscopic and robotic reoperative modalities seem safe and efficacious, although pediatric series are limited in the literature. We report the largest known series of reoperative laparoscopic ureteropelvic junction obstruction repair in children and compare this approach to primary laparoscopic pyeloplasty. MATERIALS AND METHODS: We reviewed all children undergoing laparoscopic pyeloplasty at a single institution from 2004 to 2015. Reoperative laparoscopic ureteropelvic junction obstruction repair was compared to primary pyeloplasty. Groups were analyzed regarding demographics, operative time, complications, length of hospital stay and success, defined by improvement of symptoms, ultrasound and renogram. RESULTS: We identified 11 cases of reoperation (8 redo pyeloplasties and 3 ureterocalycostomies) and 71 primary pyeloplasties. Groups were not different in age, gender or weight. Median followup was 37 months. Median time between primary pyeloplasty and reoperation was 34 months. Median operative time was 205 minutes for the reoperative group and 200 for primary pyeloplasty (p = 0.98). Length of stay was longer in the reoperative group (p = 0.049), although no major complications were recorded in this group. All reoperative cases and 96% of primary pyeloplasty cases remained asymptomatic following surgery (p = 0.99). Postoperative improvement was similar for both groups on ultrasound (90% for reoperation vs 92% for primary pyeloplasty, p = 0.99) and renogram (80% vs 88%, p = 0.6). CONCLUSIONS: Laparoscopy seems to be safe and effective for management of failed pyeloplasty in children. Based on our data, reoperation is as safe and effective as primary pyeloplasty.

Robotic Partial Nephrectomy in the Treatment of Renal Angiomyolipoma.

PURPOSE: To present the experience and efficacy of Robotic Partial Nephrectomy (RPN) for the management of renal angiomyolipomas (AMLs) with regard to renal function preservation and perioperative outcomes. PATIENTS AND METHODS: We retrospectively searched our RPN database for pathologically confirmed renal AML patients between 2006 and 2014. Clinical presentation, perioperative complications, and postoperative outcomes of the patients were analyzed. Preoperative imaging findings were reviewed to examine their ability to predict pathology of AML. RESULTS: From 1005 RPN performed in our center during the study period, 53 patients met our inclusion criteria. The mean age at presentation was 54.1 (± 13) years, and 42 (79.2%) patients were female. Median tumor size was 2.8 (interquartile range [IQR], 1.8-4.6) cm. The indication for RPN was suspicious radiologic features for malignancy in 42 (79.2%) patients and acute retroperitoneal hemorrhage risk and pain in 11 (20.8%) patients who were found to have AML according to preoperative imaging. Mean estimated blood loss was 198 (± 194) mL, and 5 (9.4%) patients required blood transfusion. Postoperative complications occurred in 8 (15%) patients. Median estimated glomerular filtration rate within the latest follow-up was 86.9 (IQR, 69.7-100.1) mL/minute/1.73 m(2) with a median of 91% (IQR, 80.4-103) preservation. None of patients developed urinary fistula or pseudoaneurysm requiring second intervention. No local recurrences occurred with a median follow-up of 7 (IQR, 1-17) months. CONCLUSION: Given the low complication rate and preservation of renal function after RPN for AML, it can be considered a reliable method for AML treatment. The majority of AMLs were not suspected based on preoperative imaging. Further diagnostic methods are needed to differentiate benign from malignant lesions.

Laparoscopic Cryoablation for Renal Cell Carcinoma: 100-Month Oncologic Outcomes.

PURPOSE: With the incidence of renal cell carcinoma on the rise treatment options for the small renal mass have broadened. Cryoablation is increasingly used as a therapeutic option for renal tumors in select cases. However, studies with long-term oncologic outcomes are sparse. We evaluated the long-term oncologic outcomes of laparoscopic renal mass cryoablation. MATERIALS AND METHODS: We reviewed our laparoscopic cryoablation database for patients treated with laparoscopic cryoablation from October 1997 to February 2005. Patients with less than 3 months of followup were excluded from study. Patient and tumor characteristics, and perioperative outcomes, including complications, were recorded. Recurrence-free, cancer specific and overall survival was analyzed using Kaplan-Meier curves. RESULTS: A total of 142 tumors in 138 consecutive patients were treated with laparoscopic cryoablation. Mean age of the cohort was 66.35 years. Of the patients 99 (71.7%) were male and 39 (28.3%) were female. Mean body mass index was 29.15 kg/m(2) and median ASA score was 3. A solitary kidney was present in 23 patients (16.2%). Mean tumor size on cross-sectional imaging was 2.4 cm. The mean preoperative and postoperative estimated glomerular filtration rate was 66.72 and 61.00 ml per minute, respectively. The postoperative estimated glomerular filtration rate was determined at a mean ± SD of 15.17 ± 10.99 months of followup. The median R.E.N.A.L. nephrometry score was 5. Of the 142 tumors 100 were diagnosed as renal cell carcinoma after histopathological examination of the biopsy specimen. At 3, 5 and 10 years in patients diagnosed with renal cell carcinoma estimated recurrence-free survival was 91.4%, 86.5% and 86.5%, estimated cancer specific survival was 96.8%, 96.8% and 92.6%, and estimated overall survival was 88.7%, 79.1% and 53.8%, respectively. Mean followup was 98.8 ± 54.2 months in those diagnosed with renal cell carcinoma. Mean time to recurrence was 2.3 years. The latest experienced recurrence was 4.4 years after laparoscopic cryoablation. There was a postoperative complication rate of 10.6% with a total of 15 complications. CONCLUSIONS: Laparoscopic cryoablation achieves good long-term oncologic outcomes for localized small renal masses. It can safely be used in patients who cannot undergo or are unwilling to accept the risks of partial nephrectomy. Mean time to recurrence was 2.3 years and all recurrences developed within 4.4 years of initial treatment.