Robotic excision of vaginal pouch in ovotesticular disorder of sexual development

ABSTRACT Purpose: Ovotesticular disorder of sexual development (DSD) is the rarest of DSDs with an incidence of 1:20000 (1). Management of vaginal pouches in such cases is warranted for symptomatic presentations and laparoscopy is considered the gold standard treatment (2). We report a rare case of robotic excision of a large symptomatic vaginal pouch in a 19-year-old boy with ovotesticular DSD. Material and Methods: A 19-year-old boy with ovotesticular DSD post hypospadias repair in early childhood presented with complaints of recurrent UTIs, ballooning of urethra during micturition and post-void dribbling. Ultrasound, voiding cystourethrogram (VCUG) and magnetic resonance imaging (MRI) were suggestive of a vaginal pouch. The patient underwent endo-evaluation followed by robot-assisted excision of the vaginal pouch. Endo-evaluation showed two orifices in the posterior urethra. The posterior orifice was leading into a blind-ending rudimentary uterus and the true urethra was lying anteriorly. The DaVinci Xi Robotic Surgical System was used and the entire pouch was dissected free of the surrounding tissues using monopolar scissors. The pouch was transected just a few millimetres from its junction with the urethra. The urethra was then closed with V-loc 4-0 suture. The patient was discharged on postoperative day 2 and the catheter was removed on day 21. Results: Follow-up VCUG at 6 weeks did not show any residual pouch. There was no complaint of post-void dribbling or UTI at 30 months of follow-up. Conclusion: Robot-assisted laparoscopy should be considered as an alternative to laparoscopy for the primary treatment of a large symptomatic vaginal pouch.

Robotic excision of vaginal pouch in ovotesticular disorder of sexual development.

PURPOSE: Ovotesticular disorder of sexual development (DSD) is the rarest of DSDs with an incidence of 1:20000 (1). Management of vaginal pouches in such cases is warranted for symptomatic presentations and laparoscopy is considered the gold standard treatment (2). We report a rare case of robotic excision of a large symptomatic vaginal pouch in a 19-year-old boy with ovotesticular DSD. MATERIAL AND METHODS: A 19-year-old boy with ovotesticular DSD post hypospadias repair in early childhood presented with complaints of recurrent UTIs, ballooning of urethra during micturition and post-void dribbling. Ultrasound, voiding cystourethrogram (VCUG) and magnetic resonance imaging (MRI) were suggestive of a vaginal pouch. The patient underwent endo-evaluation followed by robot-assisted excision of the vaginal pouch. Endo-evaluation showed two orifices in the posterior urethra. The posterior orifice was leading into a blind-ending rudimentary uterus and the true urethra was lying anteriorly. The DaVinci Xi Robotic Surgical System was used and the entire pouch was dissected free of the surrounding tissues using monopolar scissors. The pouch was transected just a few millimetres from its junction with the urethra. The urethra was then closed with V-loc 4-0 suture. The patient was discharged on postoperative day 2 and the catheter was removed on day 21. RESULTS: Follow-up VCUG at 6 weeks did not show any residual pouch. There was no complaint of post-void dribbling or UTI at 30 months of follow-up. CONCLUSION: Robot-assisted laparoscopy should be considered as an alternative to laparoscopy for the primary treatment of a large symptomatic vaginal pouch.

Analysis of causes of failure of medical treatment in patients undergoing surgery for benign prostate enlargement.

BACKGROUND: To analyse causes of failure of medical management in benign prostate enlargement (BPE) in patients who undergo surgery following medical treatment and to elucidate parameters which warrant for early surgical treatment. METHODS: Records of 747 patients who underwent surgery for BPE were reviewed for prostate volume, median lobe enlargement, post void residual urine, duration and type of medical treatment given for BPE. We used univariate and multivariate analysis to find out significant parameters for medical treatment failure. RESULTS: A total of 601 patients (80.45%) received medical treatment for their lower urinary tract symptoms (LUTS), for a duration ranging between 3 months and 2 years. Statistically significant difference was found between age, prostate volume, intravesical projection, PSA and acute urinary retention with failure of medical treatment. CONCLUSIONS: BPE patients with failure to respond with medical management within 3-6 months and/or associated with large size prostate, intravesical projection and raised serum PSA should better be offered surgical treatment.

Systemic dissemination of tumor cells during transurethral resection in patients with bladder tumor and its clinical relevance: A follow up study.

OBJECTIVE: Tumor cells are shed during transurethral resection of bladder tumor (TURBT) and form the basis for use of single dose immediate chemotherapy instillation to reduce recurrences. Systemic dissemination of these cells along with the irrigation fluid is also possible but not consistently proven. In this study, we evaluated such dissemination of tumor cells into the circulation during TURBT and its clinical impact. METHODS: Patients with primary presentation of bladder tumor who underwent TURBT were included. Peripheral venous blood samples before and after TURBT were analyzed for circulating tumor cells (CTCs) using flow-cytometry. A CD45 negative cell with positive expression of cytokeratin 18, 19, and EpCam was defined as CTC. The CTC counts, pre and post TURBT, were compared and correlated with final histopathology. The patients were also followed up for any local and/or systemic recurrences. RESULTS: Nine (16.98%) out of 53 patients developed a measurable rise in CTCs after TURBT. All of these patients had high grade and muscle invasive disease. Overall, a measurable rise in CTCs was seen in 9 out of 17 (52.94%) patients with muscle invasive disease. There was no difference in the clinico-pathological stage or the status of cystectomy and/or chemotherapy between those who did or did not show a rise in CTCs. On follow up, 7 patients with muscle invasive disease developed local and/or systemic recurrences and the rise in CTCs was not found to be associated with adverse oncological outcomes. CONCLUSIONS: This study confirms the hypothesis of inadvertent dissemination of tumor cells into the circulation during TURBT, especially in patients with high grade and muscle invasive disease. The long-term oncological impact of such dissemination remains to be confirmed.

Endoscopic holmium laser fragmentation and retrieval of migrated intravesical prolene mesh.

A 52-year-old man presented with lower urinary tract symptoms and intermittent haematuria for the last 6 months. He had undergone totally extraperitoneal right inguinal hernia repair a decade ago. The ultrasonography and an X-ray of the pelvis suggested a large radio-opaque shadow in the bladder. However, CT revealed an encrusted intravesical extension of the migrated mesh along the right anterolateral wall. The entire intravesical part of the migrated mesh with encrustations was successfully retrieved by endourological approach using holmium laser. The patient symptomatically improved and at follow-up, cystoscopy showed a complete re-epithelisation of the bladder mucosa. The intravesical extension of migrated mesh is a rare but challenging complication following mesh hernioplasty and can be successfully managed with a complete endoscopic approach.

Robotic Excision of Upper Ureteral Fibroepithelial Polyp Presenting as Pelviureteral Junction Obstruction: Surgical Surprise with Review of Literature.

Background: Fibroepithelial polyps in the upper ureter are a rare cause of pelviureteral junction obstruction (PUJO). Its diagnosis usually remains challenging by clinical and radiologic means. Case Presentation: We discuss a case of 19-year-old boy who present with intermittent left flank pain. Radiologic imaging suggested diagnosis of PUJO. We planned for robotic pyeloplasty. Intraoperatively pelviureteral junction (PUJ) was dependent, nonstenotic with upper hydroureteronephrosis creating suspicion of polyp. Keeping suspicion of polyp in upper ureter, we did robotic upper ureterotomy. This procedure revealed a 1 × 1 cm benign polyp at PUJ, which was excised completely. Conclusion: Polyps in the upper ureter constitute uncommon clinical cause of PUJO and usually diagnosed intraoperatively. Robotic approach is a feasible, acceptable, and safe option in such clinical scenario. It provides all the benefits of minimal invasive surgical procedures.

'Poles apart presentation': diagnosis and management of iatrogenic posterior urethral false tract in cases of pelvic fracture urethral injury.

Iatrogenic creation of false tract in posterior urethra while managing a case of pelvic fracture urethral injury is a dreadful complication. The spectrum of presentation ranges from complete urinary incontinence to urinary retention. We describe three such cases created due to railroading or attempted repair. Case 1 presented with total urinary incontinence following open perineal urethroplasty for posterior urethral trauma while two cases presented with failure to void after endoscopic or open surgical management for the same. One patient was managed with endoscopic resection of the septum between the false passage and true posterior urethra; two cases required redo urethroplasty. All patients voided well postoperatively and were continent. Surgeon experience and meticulous endoscopic evaluation are the keys to success. Forceful attempt at per urethral catheter placement in the acute setting should be avoided. Blind railroading of the catheter and unnecessarily forceful passage of suprapubic metal bougie during urethroplasty should be condemned.

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion biopsies increase the rate of cancer detection in populations with a low incidence of prostate cancer.

Purpose: To prospectively evaluate the diagnostic yield of multiparametric magnetic resonance imaging (mpMRI)-fusion, transrectal ultrasound (TRUS)-guided prostate biopsies for detection of prostate cancer in an Asian population with a low incidence of prostate cancer. Materials and Methods: A total of 131 males with suspected prostate cancer were recruited to undergo fusion biopsy with the Artemis prostate fusion biopsy device (Eigen, Grass Valley, CA, USA). All patients underwent standard 12-core systematic biopsies in addition to biopsies targeted at the mpMRI-identified abnormal regions. Yield from the standard cores was compared with that from the targeted cores. Gleason scores of 4+3 or higher were considered significant. Results: The mean age of the patients was 63.54±7.96 years and the mean prostate-specific antigen value was 9.75±5.35 ng/mL. A total of 36 patients had cancer, of which 3 (8.3%) were detected only on standard cores and 3 (8.3%) only on targeted cores. Of the clinically significant cancers (n=30), targeted biopsy detected a higher number (28/30, 93.3%) than standard biopsy (21/30, 70.0%). A total of 6 of 8 cancers (75.0%) that were insignificant on standard biopsy were upgraded to significant cancer on targeted cores. Conclusions: Eight percent of cancers were detected only on MRI-TRUS fusion-targeted biopsies, whereas the method upgraded more than two-thirds of insignificant cancers to significant cancers. Fusion biopsies thus provide incremental information over standard TRUS biopsies in the diagnosis of significant prostate cancer in populations with a low incidence of prostate cancer.

A comparative study of the effects of medical versus surgical androgen deprivation therapy on health-related quality of life in patients with metastatic carcinoma prostate.

INTRODUCTION: Androgen deprivation therapy (ADT) is known to adversely affect the quality of life (QoL). One may choose between surgical and medical forms depending on his economic status, education status, and taboos. The aim of this study was to assess the impact of medical versus surgical ADT on health-related quality of life (HRQoL) in patients with metastatic cancer prostate in Indian population. MATERIALS AND METHODS: From July 2012 to December 2014, 50 patients (10 medical castration and 40 surgical castration) of hormone-naïve metastatic prostate cancer who were started on combined ADT were included in this study. Before starting therapy, baseline data and QoL score (short form [SF-36] scale) were noted and all patients were followed up at 3 months, 6 months, and 1 year. Baseline data and HRQoL at all time intervals between surgical and medical castration groups were compared. RESULTS: All patients, except two, completed the 1-year follow-up period. Patients who opted for medical castration were more educated and belonged to higher socioeconomic status. For all the domains of SF-36 QoL questionnaire, a similar improvement in the score was noted at first 3-month follow-up which deteriorated in the next follow-up at 6 months and then further at 1 year. There was no difference in HRQoL after medical or surgical castration. CONCLUSIONS: In patients with metastatic cancer, prostate initiation of ADT, irrespective of method, causes an initial improvement in HRQoL followed later by a more gradual decline below the baseline.

"Targeted" prophylaxis: Impact of rectal swab culture-directed prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy.

PURPOSE: To assess the prevalence of fluoroquinolone resistance among patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy and the impact of rectal swab culture-directed antibiotic prophylaxis on postbiopsy infectious complications. MATERIALS AND METHODS: We prospectively analyzed all patients undergoing TRUS-guided prostate biopsy from April 2013 to February 2015. Antibiotic prophylaxis was tailored to the results of rectal swab cultures. If the organism was fluoroquinolone-sensitive, oral ciprofloxacin 500 mg with tinidazole 600 mg was prescribed. If the organism was fluoroquinolone-resistant, then a culture-directed antibiotic was prescribed. In both cases the antibiotic was continued for 3 days. All patients were followed for 14 days after biopsy to record infectious complications. RESULTS: A total of 247 patients were included, and Escherichia coli was isolated on rectal swab cultures in 99.5% of the patients. Of these, 41.7% harbored fluoroquinolone-resistant E. coli. Piperacillin/tazobactam was the most common culture-directed antibiotic prescribed (59.3%), with amoxicillin/clavulanic being the second most common (25.5%) for the fluoroquinolone-resistant group. Only 2 patients (0.9%) developed postbiopsy fever and none had sepsis. CONCLUSIONS: Colonization of rectal flora with fluoroquinolone-resistant E. coli was seen in 40% of men undergoing prostate biopsy. Targeted prophylaxis, which uses the results of prebiopsy rectal swab culture to direct antibiotic prophylaxis, results in low rates of postbiopsy infections.

Feasibility of dexmedetomidine as sole analgesic agent during robotic urological surgery: A pilot study.

BACKGROUND AND AIMS: Opioid-free anesthesia decreases postoperative nausea and vomiting, emergence agitation, prolonged sedation, ileus, and urinary retention. The feasibility of the use of dexmedetomidine as sole analgesic agent has been shown in patients undergoing bariatric and gynecological laparoscopic surgery. We explored its use for robotic urological surgery. MATERIAL AND METHODS: Thirty patients were randomized to receive either dexmedetomidine (Group D) or fentanyl (Group F) along with total intravenous anesthesia with propofol. The hemodynamic parameters and number of doses of rescue analgesics used intraoperatively and postoperatively were noted. Recovery parameters at the end of surgery were also recorded. RESULTS: The dose of intraoperative rescue fentanyl was not significantly different between groups (P = 0.13). The hemodynamic profile of patients in the two groups was comparable except the heart rate was significantly more in Group D after intubation and at 60 min. The mean arterial pressure was significantly lower after the initial loading dose of study drug in Group D. The recovery profiles were not significantly different between groups. CONCLUSION: The study reveals that dexmedetomidine has equal analgesic efficacy as fentanyl for intraoperative use and can be used as the sole analgesic agent in patients undergoing robotic urological surgery.

Unusual cause of renal stone following robotic pyeloplasty.

Non-absorbable Hem-o-Lok clips are commonly used for vascular pedicle control or suture stabilisation during laparoscopic or robotic reconstructive procedures. As they are placed close to suture line and with tension, these clips have a propensity to migrate. We report a case of a 22-year-old man with history of bilateral robotic pyeloplasty presenting with left inferior calyceal stone. He underwent left mini percutaneous nephrolithotomy which revealed an encrusted migrated Hem-o-Lok clip that was used to close the mesenteric window formed during transmesocolic pyeloplasty. Thus, these clips should be used sparingly and only at places where other effective alternatives are unavailable.

Sexual Dysfunction After Urethroplasty.

Posturethroplasty sexual dysfunction (SD) is multifactorial and its true incidence is unknown. Even with the current evidence suggesting that it is uncommon, de novo SD causes dissatisfaction even after a successful surgery. Posterior urethroplasty carries the highest chance of SD, mostly attributable to the pelvic fracture itself rather than the urethroplasty. With anterior urethroplasty, transecting bulbar urethroplasty leads to greater SD compared with penile or nontransecting bulbar urethroplasty. Most patients with posturethroplasty SD recover within 6 months after surgery.

Impact of assistant surgeon on outcomes in robotic surgery.

INTRODUCTION: It is believed that the outcomes of robotic surgery depends not only on the experience of the console surgeon but also the patient-side assistant. However, objective data supporting it is lacking. The aim of this study was to objectively determine change in operative outcomes with increasing experience of patient-side assistant. MATERIALS AND METHODS: We performed a retrospective analysis of 222 urologic robotic procedures performed by two teams of surgeon-assistant and split the data into two chronological halves according to date of surgery. We considered that the assistant was inexperienced in the 1(st) half and had become experienced by the 2(nd) half, and we compared mean operative time and blood loss between these two halves of his experience. RESULTS: We observed that with increasing experience of the assistant, the mean operative time reduced from 138.06 to 124.32 min (P = 0.001) and mean blood loss decreased from 191.93 to 187.61 ml (P = 0.57). On subset analysis, a consistent trend of reduction in the mean operative time was noted for both the assistants separately and for all surgical procedures included in the analysis. Maximum reduction was noted for pyeloplasty which was the most commonly performed surgery. The mean blood loss had a varied relation to the experience of the assistant and did not reach statistical significance in either direction. CONCLUSIONS: With increasing experience of the patient-side surgeon, the mean operative time for all robotic procedures showed a consistent trend of reduction across all types of surgery with greater reduction for commonly performed procedures.

Outcomes of Pyeloplasty in Very Poorly Functioning Kidneys: Examining the Myths.

OBJECTIVE: To assess the perioperative complications and functional midterm outcomes after pyeloplasty for poorly functioning kidneys due to ureteropelvic junction obstruction. PATIENTS AND METHODS: We retrospectively analyzed patients who underwent pyeloplasty for primary ureteropelvic junction obstruction in very poorly functioning kidneys in terms of split renal function of ≤20% or estimated glomerular filteration rate of ≤20 mL/minute. Perioperative complications and postoperative outcomes in terms of symptomatic improvement and functional stabilization or recovery were assessed. RESULTS: A total of 32 patients with estimated glomerular filteration rate ≤20 mL/minute or split function ≤20% underwent pyeloplasty since January 2010. All patients were followed for a mean period of 26.8 months and none required reintervention for obstructive drainage, deteriorating function, or intractable pain. One patient had persistent pain requiring analgesics and overall success rate (defined as nonobstructive pattern, no deterioration in split function, and no persistent symptoms) was 93.7%. Thirteen patients (40.6%) showed significant improvement in renal function (>5% over preoperative), and in all except 1 (3.1%) case there was no further deterioration of function. CONCLUSION: Pyeloplasty provides high rates of morphological and functional success even in very poorly functioning renal units. There is a possibility of functional recovery in one-third of patients, and in most of the rest, there is no further deterioration.

Histomorphological features of resected bladder tumors: Do energy source makes any difference.

CONTEXT: The recent advent of bipolar energy in bladder tumor resection has raised many questions regarding density of current and its effect on histopathology of the resected transurethral resection of bladder tumor (TURBT) chips. AIMS: The aim of this study is to evaluate the histomorphological features in resected bladder tumors comparing bipolar versus conventional (monopolar) energy. SETTINGS AND DESIGN: Inclusion criteria were patients with primary presentation of carcinoma urinary bladder undergoing TURBT. The patients with prior resections were excluded as these could jeopardize the results of cautery artifacts. MATERIALS AND METHODS: From February 2010 to December 2011, 61 patients with primary carcinoma bladder and meeting our inclusion criteria were compared. Group 1 (n = 31) underwent bipolar-TURBT (B-TURBT) and Group 2 (n = 30) monopolar-TURBT (M-TURBT). Two pathologists, who were blinded to the form of electrocautery used, examined the resected tissue. The degree of cautery artifact in each specimen was recorded. The severity of the cautery artifact was graded as absent, mild, moderate, or severe. The mean age, tumor size, and resection time were recorded in both groups. STATISTICAL ANALYSIS USED: Data were analyzed using SPSS 16. Data were compared in between groups using paired t-test and Pearson's Chi-square test. The significance level was set at 0.05. RESULTS: The mean age, tumor size, and resection time were similar in between the two groups. The pathologists had no obscurity in reaching a correct diagnosis in all cases. The cautery artifacts were graded as absent in 10 (32.2%) and 8 (26.67%), mild in 12 (38.7%) and 11 (36.67%), moderate in 5 (16.1%) and 7 (23.33%) and severe in 4 (12.9%) and 5 (16.66%) cases, respectively in Group 1 and 2. There was no statistically significant histomorphogical dissimilarity between specimens according to the type of cautery used. CONCLUSIONS: Bladder tissue obtained from B-TURBT is of equivalent histomorphological feature as that of standard M-TURBT.

Extraperitoneal robot-assisted laparoscopic radical prostatectomy: Initial experience.

OBJECTIVES: To report our initial experience and technique of performing robot-assisted laparoscopic radical prostatectomy (RALP) with the extraperitoneal approach. MATERIALS AND METHODS: Twenty-seven patients, between September 2010 to January 2012, were included in the study. All patients underwent extraperitoneal robot-assisted radical prostatectomy. Patients were placed supine with only 10-15(0) Trendelenburg tilt. The extraperitoneal space was developed behind the posterior rectus sheath. A five-port technique was used. After incision of endopelvic fascia and ligation of the deep venous complex, the rest of the procedure proceeded along the lines of the transperitoneal approach. RESULTS: The mean patient age, prostate size and Gleason score were 67 ± 1.8 years, 45 ± 9.55 g and 6, respectively. The mean prostate-specific antigen (PSA) was 6.50 ng/mL. The mean time required for creating extraperitoneal space, docking of robot and console time were 22, 7 and 94 min, respectively. The mean time to resume full oral feeds was 22 ± 3.45 h. There were no conversions from extraperitoneal to transperitoneal or open surgery in our series. Pathological stage was pT1, pT2a and pT3b in 11 (40.74%), 14 (51.85%) and two (7.4%) patients, respectively. Two patients had positive surgical margins and two had biochemical recurrence at the last follow-up. Our mean follow-up was 12 ± 3.30 (2-17) months. The overall continence rate was 83.33% and 92.4% at 6 and 12 months, respectively. CONCLUSIONS: Extraperitoneal RALP is an efficacious, minimally invasive approach for patients with localized carcinoma of the prostate.

Robot-assisted laparoscopic augmentation ileocystoplasty in a tubercular bladder.

Some of the patients with genitourinary tuberculosis (GUTB) present to the urologist with small contracted bladders or with significant renal damage.[1] Additional reconstructive procedures are often required along with anti-tubercular treatment in these patients. These procedures commonly performed via the open approach, now have the advantage of minimally invasive approach provided by laparoscopic and robotic surgery. The technique of robot-assisted laparoscopic augmentation ileocystoplasty in a patient with a small contracted bladder due to GUTB will be described. The procedure was performed via a completely intra-corporeal technique using an ileal "cap" created from a 15 cm segment of distal ileum which was anastomosed to the urinary bladder bi-valved in the mid-sagittal plane. The procedure lasted for 420 minutes and the patient was discharged on postoperative day 5. At 6 month follow-up, the patient has no irritative urinary symptoms and voiding with insignificant post-void residual urine.

Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor.

The treatment options in clinical stage I nonseminomatous germ cell tumor (NSGCT) of testis are either surveillance, chemotherapy or retroperitoneal lymph node dissection (RPLND). While open RPLND still serves as the gold standard, laparoscopic and robot assisted laparoscopic approaches are gaining popularity. In this report, we share our experience and technique of robot assisted laparoscopic RPLND in a patient with clinical stage Ib NSGCT of testis.