Pudendal nerve block decreases narcotic requirements and time spent in post-anesthesia care units in patients undergoing primary inflatable penile prosthesis implantation.

Efforts to minimize narcotic usage following inflatable penile prosthesis (IPP) implantation are vital, considering the current opioid epidemic in the United States. We aimed to determine whether pudendal nerve block (PNB) utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. A single-institution, retrospective study was conducted on patients who underwent primary IPP implantation between December 2015 and June 2022. PNB usage and intra- and post-operative outcomes were analyzed using multivariate binary logistic regression. 449 patients were included, with 373 (83.1%) in the PNB group. Median time (minutes) spent in the post-anesthesia care unit (PACU) (1499 [119-198] vs. 235 [169-322], p < 0.001) was significantly lower in the PNB group. There were no significant differences in intra-operative and PACU morphine milligram equivalents or post-operative safety outcomes between groups. However, fewer patients in the PNB group called for pain medications post-operatively (10.2% vs 19.7%, p = 0.019). Multivariate analysis revealed a significantly decreased operative time (B -6.23; 95%CI -11.28, -1.17; p = 0.016) and decreased time in recovery (B: -81.62; 95%CI: -106.49, -56.76, p < 0.001) in the PNB group. PNB decreases post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation and thus may represent an attractive, non-opioid adjunct.

Pure Laparoscopic Donor Nephrectomy: A Single Institution Experience From a Middle Eastern Country.

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is the most adopted technique for kidney transplantation. Several obstacles preclude brain-dead organ transplantation in the Middle East, going from social and cultural barriers to economical and structural difficulties. To our knowledge, this is the first study to report Lebanese experience with pure LLDN, and kidney transplantation. METHODS: We included 120 cases of pure LLDN performed at our center. Demographic, perioperative, and immediate postoperative data were analyzed. Surgical particularities of the technique are described. RESULTS: The reported laparoscopic technique allowed for minimal perioperative morbidity, with an overall complication rate of 3%. Operative time averaged 146 minutes and warm ischemia time averaged 4 minutes. Mean hospital stay was 3 ± 1 days. Postoperative hemoglobin and creatinine showed a mean absolute variation of 0.09 ± 0.06 g/dL for hemoglobin and 0.51 ± 015 µmoles/L increase for creatinine. No Clavien-Dindo III-V complications were recorded. CONCLUSIONS: Strict adherence to the reproducible pure LLDN technique allowed for the performance of almost 45 cases per year with minimal morbidity and results comparable to similar series.

Current controversies on the role of lymphadenectomy for prostate cancer.

Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.

Robotic Partial Nephrectomy in Patients with Chronic Kidney Disease: Objective Measurement of Short- and Long-Term Renal Functional Outcomes.

BACKGROUND: Minimal literature informs the use of robotic partial nephrectomy (RPN) in patients with chronic kidney disease (CKD). Therefore, we evaluated the renal functional outcomes in CKD patients undergoing RPN. METHODS: We reviewed a prospective database of patients undergoing RPN 2010 to 2015 and identified 182 patients who had preoperative and postoperative nuclear renal scintigraphy (at 2 and 12 months postop). Preoperative and 12-month postoperative eGFR (mL/min/1.73 m2, by MDRD) were calculated. CKD was defined as eGFR ≤60 mL/min/1.73 m2 (CKD stages III and IV). Changes in creatinine, eGFR, and split function on mercaptoacetyltriglycine (MAG)-3 scan were compared by baseline CKD status. Correlations between pre- and postoperative eGFR were calculated. RESULTS: Of 182 patients, 30 (16.5%) had baseline CKD. Preoperative eGFR was 48.5 and 99.0 in CKD and non-CKD patients, respectively (p < 0.001). From preoperation to 12 months postoperation, eGFR decreased by 2.8 and 1.1 mL/min/1.73 m2, respectively (p = 0.6). On MAG-3 scan, the contribution of the surgical kidney to overall renal function decreased by 5.0% and 4.8% (p = 0.9) in the CKD and non-CKD cohorts, respectively. When comparing renal scans at 2 and 12 months postoperation, in both groups the surgical kidney significantly recovered (both p < 0.001) and the patterns of kidney function recovery was similar in both groups (CKD +2.0%, non-CKD +1.4%, p = 0.6). On long-term follow-up (>2 years), eGFR did not change significantly in either the CKD or non-CKD group (-2.8 vs -1.1 mL/min/1.73 m2, p = 0.6). On pathology, tumors were more frequently malignant in CKD vs non-CKD patients (93.3% vs 73.2%, p = 0.02) and of higher Fuhrman Grade (grade ≥3: 49.7% vs 28.1%, p < 0.001). CONCLUSION: RPN is a reasonable treatment option in patients with CKD, as it did not lead to a greater decline in renal function contributed by the surgical kidney. The patterns of kidney function recovery after surgery are similar between patients with and without CKD.

Current management of liposarcoma of the spermatic cord: A case report and review of the literature.

Liposarcomas of the spermatic cord, a rare cause of an inguinal mass, may closely mimic inguinal hernias on clinical examination. However, these tumors require a different surgical approach and treatment plan; therefore, intraoperative diagnosis might complicate patient management. We report the case of a 63-year-old man who presented with a mobile mass in the inguinal canal consistent with an inguinal hernia. The patient was subsequently diagnosed with a liposarcoma of the spermatic cord and successfully treated with extensive local resection, including radical orchiectomy and en bloc resection of the mass and associated cord structures. No adjuvant therapy was deemed necessary, and the patient remained asymptomatic and disease-free 10 years after surgery. The details of this case are presented, along with a review and discussion of the currently available data regarding the diagnosis and management of this challenging condition.

Milestones and Basic Principles.

Current shortage in organ donors led to the expansion of criteria for organ donation placing organ preservation as one cornerstone for successful transplant, graft function and survival. The historical work of Belzer and Collins paved the way for key descriptions of physiopathology of cell ischemia and protection (cytokines roles, oxidative stress, energy shift to lactic acidosis and perfusion pressure changes). Good preservation means immediate recovery of function and prevention of chronic rejection. Two cooling approaches are available: static (SCS: simple cold storage) suitable for all organs, and dynamic (HMP: hypothermic machines perfusion) designed for kidneys and liver. A thorough discussion of historically manufactured and widely sold preservation solutions e.g. EuroCollins, UW solution (Viaspan®) as well as current used solutions e.g. Custodiol® and the new Celsior is available in this review. Obviously, every single organ exhibits different tolerance to warm and cold ischemia depending on its nature and demands after transplant. Future perspectives of organ preservation may be hidden in hibernators which may hold the enigmas of perfect human organ preservation.

Surgical management of pelvic organ prolapse in women: how to choose the best approach.

Although benign, pelvic organ prolapse is a real public health problem, affecting mostly women above sixty-five. Eighty-year-old women have an 11.1% lifetime risk of undergoing surgery for prolapse or stress urinary incontinence and 29% will need a second procedure. Surgical approach may be abdominal (sacrocolpopexy by laparotomy, laparoscopy or robot-assisted) or vaginal (autologous, or prosthetic reinforcement). In addition to anatomical correction, surgical objectives include: improvement of the patient's quality of life, prolapse symptoms relief, normal urinary, digestive and sexual functions and especially, avoiding iatrogenic sequelae. Thus, the choice of the surgical approach does not only depend upon the site and the severity of the prolapse. Urogynecological surgeons should take into consideration the patient's expectations and life style, her age--a determinant factor in deciding upon the best approach -, and her relapse risk factors. They should master both approaches, and the management of surgical complications. Therefore, an apprenticeship in a reference pelviperineology center is a must. In addition, surgeons should be aware of and consider contraindications to each procedure, for instance contraindications to transvaginal prosthesis reinforcement like risk factors of bad healing or infection. Urogynecology specialists have to take into consideration known anatomical and functional results of each technique as cited in the medical literature and act in accordance with international recommendations. The surgery's main objective is to ameliorate the patient's discomfort and her quality of life without causing iatrogenic dysfunctional symptoms (urinary, digestive, sexual). The pelvic organ prolapse being a benign pathology, the patient's satisfaction is the main marker of the procedure success. In short, regarding the surgical management of pelvic organ prolapse in women the answer to the question How to choose the best approach? is not binary. It depends on several factors, and regardless of the choice, it must

[From the open approach to laparoscopy. Background, rationale, technique]. / La promontofixation: de la voie ouverte a la coelioscopie. Historique, rationnel, technique.

Genital prolapse is a frequent functional pathology in women. Its surgical treatment depends specially upon the suspension and fixation of the vaginal vault. Thus, sacrocolpopexy has become a gold standard technique to correct genital prolapse. Laparoscopy is a procedure resulting in less bleeding and decreased hospital stay than open sacrocolpopexy and is presently the approach of choice. Its objective and subjective correction rates are > 90%. Some authors proposed a dual abdominal and perineal approach to help fixing the posterior mesh and repairing the perineal body. Robotics is the actual surgeons' gadget.Its results are similar to laparoscopic sacrocolpopexy albeit a higher cost and a longer operating time. The ideal mesh is monofilamentous with large pores. Sacrocolpopexy consists in fixing two meshes, one on the anterior vaginal wall and one on the posterior vaginal wall, on the anterior sacral ligament, without tension for the posterior mesh, with or without subtotal hysterectomy, and with closure of the peritoneum at the end. In the case of associated stress urinary incontinence, proved on the clinical exam or urodynamical exam, appropriate surgical treatment is done with sacrocolpopexy. In the near future, robotics will replace laparoscopy when costs will be reduced and medical staff well trained to perform robotic or robot-assisted sacrocolpopexy.