Feasibility of outpatient laparoscopic adrenalectomy for primary aldosteronism.

OBJECTIVE: Laparoscopic adrenalectomy (LA) has emerged as the gold standard for the management of adrenal diseases. Despite its low complication rate, the utilization of LA in outpatient settings remains limited. This study explored the feasibility of outpatient LA for primary aldosteronism (PA). DESIGN & METHODS: A retrospective analysis was conducted by reviewing the medical records of consecutive LA procedures performed for PA in our department from 2013 to 2021. A successful outpatient procedure was defined as same-day discharge, less than 12 hours after admission, with no readmission within 48 hours. A postoperative day one (D1) follow-up call by a nurse assessed complications, pain, and patient satisfaction (Numeric Rating Scale [0-10]). Follow-up visits were scheduled at one, three, and six months. RESULTS: During the study period, 76 LAs were performed for PA, with 60 (78.9%) being outpatient procedures. Sixteen patients (21.9%) were not selected for outpatient procedures. The main reasons for contraindicating outpatient procedures were anesthetic or social issues. The success rate of the outpatient procedures was 95% (57/60), with no reported surgical complications. Prolonged hospitalization occurred due to medical reasons such as pain or vomiting. There were no readmissions within 48 hours after discharge. The mean pain and patient satisfaction, evaluated at D1, were 2.1/10 and 9.4/10, respectively. At 6 months, 32 patients (59.2%) were cured without any antihypertensive drugs, and 15 (27.8%) were improved (reduction of their antihypertensive treatment). CONCLUSION: Outpatient LA for PA has demonstrated feasibility with a high success rate, no readmissions, low postoperative pain, and a high level of patient satisfaction.

Partial gland ablation with high intensity focal ultrasound impact on genito-urinary function and quality of life: our initial experience.

INTRODUCTION:   Partial gland ablation (PGA) using high intensity focal ultrasound (HIFU) is an alternative to active surveillance for low to intermediate risk localized prostate cancer.  This pilot study assessed quality of life (QoL) outcomes during the implementation of PGA-HIFU at our institution. MATERIALS AND METHODS:   We prospectively enrolled 25 men with a diagnosis of localized low/intermediate risk prostate cancer who elected to undergo PGA-HIFU in a pilot study at our institution between 2013 and 2016.  Patients underwent pre-treatment mpMRI and transrectal ultrasound-guided biopsies.  The primary endpoints were impact on patient-reported functional outcomes (erectile, urinary function, QoL) assessed at 1, 3, 6- and 12-months. RESULTS:   The median age was 64 years old (IQR 59.5-67).  Baseline median International Index of Erectile Function-15 score was 50, which decreased to 18 at 1 month (p < 0.0005), returned to baseline by 3 months and thereafter. International Prostate Symptom Score median at baseline was 8, which worsened to 12 at 1 month (p = 0.0088), and subsequently improved to baseline thereafter.  On the UCLA-Expanded Prostate Cancer Index Composite urinary function, there was a decrease in median score from 92.7 at baseline to 76.0 at 1 month (p < 0.0001), which improved to or above baseline afterwards.  QoL remained similar to baseline at each follow up period as assessed by EQ-5D and the Functional Cancer Therapy-Prostate score. CONCLUSIONS:   In this initial cohort of PGA-HIFU men at our institution, patients demonstrated a slight, but transient, deterioration in urinary and erectile function at 1 month prior to normalization.  All QoL metrics showed no impact upon 1 year of follow up post-treatment.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion.

OBJECTIVE: To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use. PATIENTS AND METHODS: A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC. RESULTS: Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed. CONCLUSIONS: For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Biopsy characteristics in men with a preoperative diagnosis of prostatic adenocarcinoma with high Gleason score (8-10) predict pathologic outcome in radical prostatectomy.

Even if limited to one biopsy core, most urologists and radiation oncologists use the highest Gleason score (GS) to guide therapy. To evaluate the suitability of using biopsy characteristics to predict tumor characteristics at radical prostatectomy (RP) in men with high biopsy GS (BGS) cancer to better select men who will most benefit from various local therapies, we retrospectively reviewed the biopsy and RP findings of 144 men with a BGS 8-10. One hundred six and 38 patients with a BGS of 8 and 9-10, respectively, were included. Forty-eight percent of cases were downgraded to a final GS of 7 at RP, including 54% of BGS 8, and 32% of BGS 9-10 group. Overall, 31% had pT2 disease at RP. Multiple biopsy features, including the GS, the number of positive cores, the number of cores with high-GS cancer, and the maximum volume of high-grade cancer per core (MVPC) consistently predicted final GS and RP tumor stage. Multivariate analysis showed that biopsy GS and MVPC were independent predictors of final GS, while MVPC was also an independent predictor for final pT stage. Patients with high BGS are not a homogeneous group in terms of local tumor characteristics. In addition to BGS (9-10 being worse than 8), other biopsy findings, especially the number of involved cores, number of cores with high-BGS cancer, and MVPC are important predictors of findings at RP that should be incorporated in the decision treatment planning. Most patients with only one core BGS 8 cancer harbor GS 7 cancer.

Robotic-assisted radical nephrectomy for renal angiomyolipoma with inferior vena cava thrombus extension.

Renal angiomyolipoma with inferior vena caval venous extension is rare with only 40 cases reported in the literature. We report a case of a 35-year-old lady with angiomyolipoma with inferior vena caval thrombus that was managed surgically with robotic-assisted radical nephrectomy.

Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines: A pilot study.

OBJECTIVE: In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines. METHODS: In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1-74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons. RESULTS: The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05). CONCLUSIONS: This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts.

Percutaneous radiofrequency ablation of small renal tumors using CT-guidance: a review and its current role.

PURPOSE: To provide key evidence-based strategies to improve outcomes of radiofrequency ablation and limit recurrences of small renal tumors. MATERIALS AND METHODS: The literature was searched via OvidSP MEDLINE from 1997 to current using MeSH terms. All levels of evidence and types of reports were reviewed. RESULTS: We comprehensively reviewed technical issues, mechanisms, imaging criteria, ablative success, enhancement within one month, contraindications, oncological efficacy, morbidity rates, and follow-up strategies. CONCLUSION: The technique is safe and effective. Tumors < 2.5 cm are statistically most likely to remain disease-free. Anterior tumors are contraindicated. Strict follow-up is needed to detect failures, most of which occur within 3 months and can be easily salvaged with repeat radiofrequency ablation. Homogeneous enhancement within 1 month is not necessarily a failure, and tends to disappear after 4 to 6 weeks. Multi-disciplinary meetings must occur to discuss each case prior to treatment.

Urethral device in women with chronic urinary retention: an alternative to self-catheterization?

OBJECTIVE: To assess the efficacy and safety of a new urethral prosthesis in the management of chronic urinary retention in women as an alternative to intermittent or indwelling catheterization. METHODS: Between May 1999 and July 2000, 60 women with chronic urinary retention were prospectively enrolled in the study. The prosthesis was inserted under local anaesthesia. A magnetic control unit activates the urethral device to achieve micturition. Duration of the experience, complications and compliance were evaluated. RESULTS: Thirty patients were satisfied with the device. Discontinuation occurred in the first two weeks following implantation in 50% of cases. Bladder migration of the prosthesis occurred in two cases, urinary leakage around the device in four patients, spontaneous expulsion in two women and cystitis was diagnosed in two cases. CONCLUSION: This intraurethral prosthesis is an attractive, simple technique for use as an alternative to catheterization. Some untoward events and technical complications explained the number of discontinuations.

Minimally invasive surgery for female urinary incontinence: experience with periurethral microballoon implantation.

PURPOSE: To assess the effectiveness of periurethral microballoon implantation for management of female urinary incontinence. PATIENTS AND METHODS: A total of 45 women with urinary incontinence (age range 47-88 years) were treated between May 2000 and June 2001. Microballoons were placed in the proximal periurethral tissue using endoscopic instrumentation under local anesthesia. Follow-up assessment including urodynamic study and quality- of-life assessment was performed at 1, 3, and 6 months. RESULTS: Implantation was successful in all cases with no significant adverse effects. Cure was achieved in 60% and improvement in 5%. The failure rate was 35%. Microballoon implantation significantly increased the mean urethral closure pressure, from 35.2 cm H(2)O (SD 14.9; range 15-72 cm H(2)O) to 46.5 cm H(2)O (SD 19.7; range 16-87 cm H(2)O) (P = 0.001). The best predictors of successful outcome in univariate analysis were initial urethral closure pressure (P = 0.047) and degree of incontinence (P < 0.001). CONCLUSIONS: Periurethral microballoon implantation is a useful technique for the management of female urinary incontinence, especially in elderly and inoperable patients. The microballoons do not present the adverse effects associated with other bulking agents.