Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis.

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Tamsulosin vs. Tadalafil as medical expulsive therapy for distal ureteral stones: a systematic review and meta-analysis

ABSTRACT Purpose: Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile. Materials and methods: A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis. Results: Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension. Conclusion: Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects.

Tamsulosin vs. Tadalafil as medical expulsive therapy for distal ureteral stones: a systematic review and meta-analysis.

PURPOSE: Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile. MATERIALS AND METHODS: A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis. RESULTS: Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension. CONCLUSION: Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study.

INTRODUCTION: Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB). METHODS: a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed. RESULTS: there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II. CONCLUSIONS: simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study / Hernioplastia inguinal pré-peritoneal transabdominal bilateral e varicocelectomia laparoscópica bilateral na mesma intervenção: um estudo de viabilidade

ABSTRACT Introduction: Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB). Methods: a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed. Results: there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II. Conclusions: simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

RESUMO Introdução: hérnia inguinal e varicocele são doenças comuns na população masculina. O advento da laparoscopia traz a oportunidade de tratá-las simultaneamente, pelo mesmo acesso. Entretanto, existem divergências sobre os riscos para a perfusão testicular de múltiplos procedimentos na região inguinal. Neste estudo, avaliamos a viabilidade de procedimentos laparoscópicos simultâneos estudando resultados clínicos e cirúrgicos de pacientes submetidos à hernioplastia inguinal bilateral pela técnica transabdominal préperitoneal (TAPP) com e sem varicocelectomia laparoscópica bilateral (VLB) concomitante. Métodos: uma amostra de 20 pacientes do Hospital Universitário da USP-SP com hérnia inguinal indireta e varicocele com indicação de correção cirúrgica foi selecionada. Os pacientes foram randomizados em dois grupos, sendo 10 submetidos à TAPP (Grupo I) e 10 submetidos à TAPP e VLB simultâneas (Grupo II). O tempo operatório total, complicações e dor pós-operatória foram coletados e analisados. Resultados: não houve diferença estatística entre os grupos com relação ao tempo operatório total e à dor pós-operatória. Apenas uma complicação (hematoma do cordão espermático) foi observada no Grupo I e não foram observadas complicações no Grupo II. Conclusões: no mesmo procedimento, submeter pacientes à TAPP e à VLB no mesmo procedimento se mostrou eficaz e seguro, o que fornece embasamento para a realização de estudos em maiores escalas.

Learning curve of semi-rigid ureteroscopy for small calculi: how many cases are necessary?

INTRODUCTION: semi-rigid ureteroscopy is the procedure of choice for the treatment of ureterolithiasis, but it requires a learning curve to be performed safely. OBJECTIVE: To describe an estimate of the learning curve for performing semi-rigid ureterorenolithotripsy in patients with small-sized ureterolithiasis and to estimate the minimum number of procedures necessary to safely perform the surgical procedure. METHODS: this is a prospective study evaluating the learning curve of a resident of urology in the first 60 semirigid ureteroscopies in patients with ureterolithiasis up to 1cm. The patients were divided into three groups: Group I one to twenty surgeries, Group II twenty one to forty surgeries and Group III forty one to sixty surgeries. The surgeries were recorded and analyzed by two urologists experienced in endourology. A qualitative analysis was performed based on a previously validated tool and a quantitative analysis. RESULTS: all qualitative variables had significant variation between Groups I and II (p<0.001), and between Groups I and III (p<0.001). There was a difference in time to access the ureter, passage of a double J catheter and total operative time between Groups I and II (p<0.001) and Groups I and III (p<0.001). CONCLUSION: after 40 cases there seems to be little increase in both quantitative as well as qualitative evaluation in surgical performance for performing semi-rigid ureterolithotripsy safely in calculations up to 1cm.

Learning curve of semi-rigid ureteroscopy for small calculi: how many cases are necessary? / Curva de aprendizado em ureteroscopia semi-rígida em cálculos de pequenas dimensões: quantos casos são necessários?

ABSTRACT Introduction: semi-rigid ureteroscopy is the procedure of choice for the treatment of ureterolithiasis, but it requires a learning curve to be performed safely. Objective: To describe an estimate of the learning curve for performing semi-rigid ureterorenolithotripsy in patients with small-sized ureterolithiasis and to estimate the minimum number of procedures necessary to safely perform the surgical procedure. Methods: this is a prospective study evaluating the learning curve of a resident of urology in the first 60 semirigid ureteroscopies in patients with ureterolithiasis up to 1cm. The patients were divided into three groups: Group I one to twenty surgeries, Group II twenty one to forty surgeries and Group III forty one to sixty surgeries. The surgeries were recorded and analyzed by two urologists experienced in endourology. A qualitative analysis was performed based on a previously validated tool and a quantitative analysis. Results: all qualitative variables had significant variation between Groups I and II (p<0.001), and between Groups I and III (p<0.001). There was a difference in time to access the ureter, passage of a double J catheter and total operative time between Groups I and II (p<0.001) and Groups I and III (p<0.001). Conclusion: after 40 cases there seems to be little increase in both quantitative as well as qualitative evaluation in surgical performance for performing semi-rigid ureterolithotripsy safely in calculations up to 1cm.

RESUMO Introdução: ureteroscopia semi-rígida é o procedimento de escolha para o tratamento da ureterolitíase, mas necessita de uma curva de aprendizado para ser executada com segurança. Objetivo: descrever uma estimativa da curva de aprendizado para realização da ureterorrenolitotripsia semi-rígida em pacientes com ureterolitíase de pequena dimensão e estimar o número mínimo de procedimentos necessários para realizar o procedimento cirúrgico com segurança. Métodos: trata-se de um estudo prospectivo avaliando a curva de aprendizado de um residente de urologia nas primeiras 60 ureteroscopias semi-rígidas em pacientes com ureterolitíase até 1cm. Os pacientes foram divididos em três grupos: Grupo I uma a vinte cirurgias, Grupo II vinte e uma a quarenta cirurgias e Grupo III quarenta e uma a sessenta cirurgias. As cirurgias foram gravadas e analisadas por dois urologistas experientes em endourologia. Foi feita uma análise qualitativa baseada em uma ferramenta previamente validada e uma análise quantitativa. Resultados: todas as variáveis qualitativas tiveram variação significativa entre os Grupos I e II (p<0.001), e entre os Grupos I e III (p<0.001). Houve diferença no tempo para acesso ao ureter, passagem de cateter duplo J e tempo operatório total entre os Grupos I e II (p<0.001) e nos Grupos I e III (p<0.001). Conclusão: após 40 casos parece haver pouco incremento tanto na avaliação quantitativa bem como na avaliação qualitativa em performance cirúrgica para a realização de ureterolitotripsia semi-rígida com segurança em cálculos de até 1cm.

Assessment of the lower urinary tract symptoms after robotic-assisted radical prostatectomy: the behavior of voiding, storage and post micturition symptoms.

INTRODUCTION: despite being infrequent, urinary incontinence has a huge impact on the quality of life of patients undergoing radical prostatectomy, even with the robotic-assisted technique. OBJECTIVE: to assess the evolution of urinary symptoms from preoperative to 12 months after robotic-assisted radical prostatectomy. METHODS: data was collected from 998 patients who underwent robotic-assisted radical prostatectomy. Demographic data, preoperative and postoperative information on patients were documented. The ICIQ and IPSS questionnaires were also applied preoperatively and after 1, 3, 6 and 12 months after the operation. Results: Out of 998 patients, 257 correctly completed all questionnaires. The mean age of the patients was 60 ± 0.74 years. We found that the total IPSS increased initially and at 6 months after the operation, it was already lower than the initial preoperative value (7.76 at 6 months vs. 9.90 preoperative, p <0.001), being that questions regarding voiding symptoms were the first to improve followed by the questions regarding post micturition and storage symptoms. As for the ICIQ variables, there was an increase with radical prostatectomy and none of them returned to the preoperative level (p<0.001). CONCLUSIONS: robotic assisted radical prostatectomy causes, at first, a worsening of urinary symptoms in the lower tract with subsequent recovery. Recovery begins with voiding symptoms, followed by post micturition and storage symptoms. The symptoms assessed by the IPSS evolve to better parameters even than those of the preoperative period, while the symptoms of incontinence assessed by the ICIQ do not reach the preoperative levels in the studied interval.

Digital application developed to evaluate functional results following robot-assisted radical prostatectomy: App for prostate cancer.

INTRODUCTION: Mobile applications ("apps") developed for smartphones and tablets are increasingly used in healthcare, allowing remote patient support or promoting self-health care. Prostate cancer (PC) screening allows for early-stage PC diagnosis, resulting in high rates of curative procedures such as radical prostatectomy. The main complications following surgery are urinary incontinence and erectile dysfunction. However, the exact numbers related to these morbidities are often missing due to brief interviews during consultations in the medical office. Therefore, the aim of this study was to create an app to determine whether response rates to pre- and post-surgical PC questionnaires will increase. METHODS: The app was built using the IONIC framework system and provided to patients through a prospective randomized study. We included 100 patients divided into two groups: 1. first group used the app (n = 50); and 2. second group responded via validated printed questionnaires (control group) (n = 50). All patients received discharge counseling to respond to the questionnaires 1, 3, 6 and 12 months after the procedure. The app group received verbal guidance on how monitoring would occur, received an SMS containing a username and password providing access to the system and received reminder alerts to respond to the questionnaires. RESULTS: The new app is called UroHealth and is available for download in the Apple App Store or at www.urohealth.com.br. When we evaluated the response rates, we found that 42.9% of the patients answered the preoperative questionnaire in the app group, while 16% responded in the control group (p = 0.003). By the end of the follow-up, we found that 24.5% of the patients answered the questionnaire in the app group, while 4% responded in the control group (p = 0.003). CONCLUSION: This app enabled almost 6 times more patients to answer long-term follow-up questions after surgical procedures, providing high-quality information regarding morbidity related to treatment. Although our initial results indicate that this app may become a useful tool in obtaining more frequent and realistic answers, thus helping to improve surgical techniques, other ways of reaching the patient should be tested to achieve higher response rates.

Assessment of the lower urinary tract symptoms after robotic-assisted radical prostatectomy: the behavior of voiding, storage and post micturition symptoms / Avaliação dos sintomas do trato urinário inferior após prostatectomia radical robótica-assistida: o comportamento dos sintomas de esvaziamento, armazenamento e pós-miccionais

ABSTRACT Introduction: despite being infrequent, urinary incontinence has a huge impact on the quality of life of patients undergoing radical prostatectomy, even with the robotic-assisted technique. Objective: to assess the evolution of urinary symptoms from preoperative to 12 months after robotic-assisted radical prostatectomy. Methods: data was collected from 998 patients who underwent robotic-assisted radical prostatectomy. Demographic data, preoperative and postoperative information on patients were documented. The ICIQ and IPSS questionnaires were also applied preoperatively and after 1, 3, 6 and 12 months after the operation. Results: Out of 998 patients, 257 correctly completed all questionnaires. The mean age of the patients was 60 ± 0.74 years. We found that the total IPSS increased initially and at 6 months after the operation, it was already lower than the initial preoperative value (7.76 at 6 months vs. 9.90 preoperative, p <0.001), being that questions regarding voiding symptoms were the first to improve followed by the questions regarding post micturition and storage symptoms. As for the ICIQ variables, there was an increase with radical prostatectomy and none of them returned to the preoperative level (p<0.001). Conclusions: robotic assisted radical prostatectomy causes, at first, a worsening of urinary symptoms in the lower tract with subsequent recovery. Recovery begins with voiding symptoms, followed by post micturition and storage symptoms. The symptoms assessed by the IPSS evolve to better parameters even than those of the preoperative period, while the symptoms of incontinence assessed by the ICIQ do not reach the preoperative levels in the studied interval.

RESUMO Introdução: apesar de infrequente, a incontinência urinária gera imenso impacto na qualidade de vida dos pacientes submetidos a prostatectomia radical, mesmo com a técnica robótica-assistida. Objetivo: avaliar a evolução dos sintomas urinários desde o pré-operatório até 12 meses após a prostatectomia radical robótica-assistida. Métodos: foram coletados os dados de 998 pacientes submetidos à prostatectomia radical robótica-assistida. Foram documentados dados demográficos, informações pré-operatórias e pós-operatórias dos pacientes. Também foram aplicados os questionários ICIQ e IPSS no pré-operatório e após 1, 3, 6 e 12 meses de pós-operatório. Resultados: de 998 pacientes, 257 preencheram corretamente todos os questionários. A idade média dos pacientes foi de 60±0,74 anos. Verificou-se que o IPSS total subia inicialmente e aos 6 meses após a operação, este já se tornava inferior ao valor inicial pré-operatório (7,76 aos 6 meses vs. 9,90 pré-operatório, p<0.001), sendo que as questões referentes a sintomas de esvaziamento foram as primeiras a melhorar e posteriormente as questões referentes a sintomas pós-miccionais e de armazenamento. Quanto às variáveis do ICIQ, houve elevação com a prostatectomia radical e nenhuma delas retornou ao patamar pré-operatório (p<0,001). Conclusões: a prostatectomia radical robótica assistida causa num primeiro momento uma piora nos sintomas urinários do trato inferior com uma recuperação subsequente. A recuperação se inicia pelos sintomas de esvaziamento, seguido dos sintomas pós-miccionais e de armazenamento. Os sintomas avaliados pelo IPSS acabam evoluindo a parâmetros melhores inclusive que os do pré-operatório, enquanto os sintomas de perda urinária avaliados pelo ICIQ não atingem os níveis pré-operatórios no intervalo estudado.

Is Age an Independent Factor for Prostate Cancer? A Paired Analysis.

INTRODUCTION: Prostate cancer is the most prevalent malignant neoplasia among men worldwide. Several prognostic factors, including Gleason's score, the measurement of serum prostate-specific antigen (PSA) and the evaluation of the percentage of fragments affected by cancer on prostate biopsy, have already been established. Age alone, however, has yet to be studied as a prognostic factor independently from other known factors. The aim of the present study was to compare the characteristics and the evolution of prostate cancer in different age groups using a paired analysis for patients with equivalent known prognostic factors. In addition, we aimed to determine the true impact of age on the prognosis of prostate cancer. MATERIAL AND METHODS: The data from 2,283 patients subjected to radical retropubic prostatectomy between 1998 and 2009 were reviewed. The patients were divided into three age groups: < 55 years old, between 56 and 65 and > 65 years old. Each patient was matched to another patient in the other groups who had the same PSA range (< 4.0, between 4.0 and 10.0 and > 10), Gleason score on the surgical specimen and prognostic range of positive fragments in the prostate biopsy (< 33%, between 34 and 50% and > 50%). After pairing, each group consisted of 215 patients, who were compared using the biochemical recurrence of the disease (PSA > 0.2), the interval for biochemical relapse, extra-capsular invasion and invasion of the seminal vesicles or the lymph nodes. RESULTS. No significant difference was observed between the groups regarding the frequency of relapses, interval of relapse, extra-capsular invasion and invasion of the seminal vesicles or lymph nodes. DISCUSSION: None of the studied factors were affected by the age of the patients. Therefore, patients of different ages had tumors with similar characteristics and behaviors. CONCLUSION: When assessed separately, without the effects of the main prognostic factors, age does not appear to be an independent prognostic factor for prostate cancer.

Quality of life in young adult patients treated for bladder exstrophy.

INTRODUCTION: Bladder exstrophy (BE) is a rare condition that requires complex surgical corrections to achieve the goals of bladder functionality, normal sexual function, continence, and finally cosmesis. The purpose of this study was to identify clinical parameters that predict better quality of life (QOL) scores using a validated questionnaire (SF-36) with young adults after completing surgical reconstruction. MATERIAL AND METHODS: Forty-three young adults (mean age 22.35 years, 29 men and 14 women) treated for BE were evaluated using the Short Form 36 general health questionnaire (SF-36). Clinical assessment involved evaluation of the actual condition regarding continence, sexual function, genital satisfaction and overall cosmesis. RESULTS: Both genders presented similar QOL scores (p = 0.36). The QOL was not age-related (p = 0.63). Neither genders did not present any differences in the number of procedures (p = 0.27). Although no significant gender difference was found, clinical impairments - such as urinary fistula, incontinence, penile length and infertility - were associated with worse QOL scores and were male-related (p <0.01). The most common complaint after complete surgical repair was about penile length (26/29 patients, 89.6%). CONCLUSIONS: Age and gender were not predictors of better QOL scores. Any clinical impairment, such as urinary leakage due to incontinence or fistula, penile length and infertility, tended to significantly decrease the overall QOL in male patients with BE. The male genitalia seems to be the most troublesome aspect post-adolescence in treated male patients with exstrophy-epispadias. It has an important impact on the overall QOL, mainly having a social affect on those patients.

Does Warm-Up Training in a Virtual Reality Simulator Improve Surgical Performance? A Prospective Randomized Analysis.

INTRODUCTION: Virtual reality surgical simulators (VRSS) have been showing themselves as a valuable tool in laparoscopy training and education. Taking in consideration the effectiveness of the VRSS, new uses for this tool have been purposed. In sports, warming up before exercise clearly shows benefit in performance. It is hypothesized that warming up in the VRSS before going to the operating room may show benefit in surgical performance. OBJECTIVE: Verify whether there is benefit in surgical performance with preoperatory warm-up using a VRSS. MATERIALS AND METHODS: A total of 20 medical students with basic knowledge in laparoscopy were divided in 2 groups (I and II). Group I performed a laparoscopic cholecystectomy in a porcine model. Group II performed preoperative warm-up in a VRSS and then performed a laparoscopic cholecystectomy in a porcine model. The performance between both groups was compared regarding quantitative parameters (time for dissection of the gallbladder pedicle, time for clipping the pedicle, time for cutting the pedicle, time for gallbladder removal, total operative time, and aspirated blood loss) and qualitative parameters (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) based on a previously validated score system, in which the higher the score, the better the result. Data were analyzed with level of significance of 5%. RESULTS: The group that underwent preoperative warm-up (group II) showed significantly superior results as to the time for dissection of the gallbladder pedicle (11.91 ± 9.85 vs. 4.52 ± 2.89min, p = 0.012), time for clipping the pedicle (5.51 ± 2.36 vs. 2.89 ± 2.76min, p = 0.004), time for cutting the pedicle (1.84 ± 0.7 vs. 1.13 ± 0.51, p = 0.019), aspirated blood loss (171 ± 112 vs. 57 ± 27.8ml, p = 0.006), depth perception (4.5 ± 0.7 vs. 3.3 ± 0.67, p = 0.004), bianual dexterity (4.2 ± 0.78 vs. 3.3 ± 0.67, p = 0.004), tissue handling (4.2 ± 0.91 vs. 3.6 ± 0.66, p = 0.012), and autonomy (4.9 ± 0.31 vs. 3.6 ± 0.96, p = 0.028). There was no difference in time for gallbladder removal (11.58 ± 4.31 vs. 15.08 ± 4.51min, p = 0.096), total operative time (30.8 ± 11.07 vs. 25.60 ± 5.10min, p = 0.188), and efficiency (4 ± 0.66 vs. 3.6 ± 0.69, p = 0.320). CONCLUSION: The practice of preoperative warm-up training seems to benefit surgical performance even in subject with mild laparoscopic experience.

Robotic-assisted laparoscopic partial nephrectomy: initial experience in Brazil and a review of the literature.

CONTEXT AND PURPOSE: Partial nephrectomy has become the standard of care for renal tumors less than 4 cm in diameter. Controversy still exists, however, regarding the best surgical approach, especially when minimally invasive techniques are taken into account. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has emerged as a promising technique that helps surgeons achieve the standards of open partial nephrectomy care while offering a minimally invasive approach. The objective of the present study was to describe our initial experience with robotic-assisted laparoscopic partial nephrectomy and extensively review the pertinent literature. MATERIALS AND METHODS: Between August 2009 and February 2010, eight consecutive selected patients with contrast enhancing renal masses observed by CT were submitted to RALPN in a private institution. In addition, we collected information on the patients ' demographics, preoperative tumor characteristics and detailed operative, postoperative and pathological data. In addition, a PubMed search was performed to provide an extensive review of the robotic-assisted laparoscopic partial nephrectomy literature. RESULTS: Seven patients had RALPN on the left or right sides with no intraoperative complications. One patient was electively converted to a robotic-assisted radical nephrectomy. The operative time ranged from 120 to 300 min, estimated blood loss (EBL) ranged from 75 to 400 mL and, in five cases, the warm ischemia time (WIT) ranged from 18 to 32 min. Two patients did not require any clamping. Overall, no transfusions were necessary, and there were no intraoperative complications or adverse postoperative clinical events. All margins were negative, and all patients were disease-free at the 6-month follow-up. CONCLUSIONS: Robotic-assisted laparoscopic partial nephrectomy is a feasible and safe approach to small renal cortical masses. Further prospective studies are needed to compare open partial nephrectomy with its minimally invasive counterparts.

MMP-9 overexpression due to TIMP-1 and RECK underexpression is associated with prognosis in prostate cancer.

BACKGROUND: Extracellular matrix homeostasis is strictly maintained by a coordinated balance between the expression of metalloproteinases (MMPs) and their inhibitors. The purpose of this study was to investigate whether the expression of MMP-9 and its specific inhibitors, TIMP-1 and RECK, are expressed in a reproducible, specific pattern and if the profiles are related to prognosis and clinical outcome in prostate cancer (PC). METHODS: MMP-9, TIMP-1, and RECK expression levels were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR) in fresh-frozen malignant tissue specimens collected from 79 patients with clinically localized PC submitted to radical prostatectomy (RP). Frozen benign prostatic tissue from another 10 men with prostate cancer, also submitted to RP, was analyzed to determine if the profile of gene expression was maintained. The control group consisted of 11 patients with benign prostate hyperplasia (BPH). RESULTS: In the tumor samples, MMP-9 was overexpressed by 9.2 times, and TIMP-1 and RECK were underexpressed (0.75 and 0.80 times, respectively). Overexpression of MMP-9 was significantly related to PSA levels above 10 ng/mL (p=0.033). In addition, MMP-9 overexpression was related to biochemical recurrence, with a marginal statistical significance (p=0.089). MMP-9 was also overexpressed in benign tissues of patients with PC, as were TIMP-1 and RECK, in contrast to their underexpression in tumor samples. CONCLUSION: Our results show that MMP-9 is overexpressed and its negative regulators are underexpressed in PC tissue, emphasizing a possible role of MMP-9 in the carcinogenesis process. Additionally, we noticed a relationship between MMP-9 overexpression and increased levels of PSA, an important prognostic factor. In benign tissue adjacent to tumors, the MMP-9 equilibrium is likely maintained because the expression of its negative regulators is preserved.

Does training laparoscopic skills in a virtual reality simulator improve surgical performance?

BACKGROUND AND PURPOSE: Several different methods of teaching laparoscopic skills have been advocated, with virtual reality surgical simulation (VRSS) being the most popular. Its effectiveness in improving surgical performance is not a consensus yet, however. The purpose of this study was to determine whether practicing surgical skills in a virtual reality simulator results in improved surgical performance. MATERIALS AND METHODS: Fifteen medical students recruited for the study were divided into three groups. Group I (control) did not receive any VRSS training. For 10 weeks, group II trained basic laparoscopic skills (camera handling, cutting skill, peg transfer skill, and clipping skill) in a VRSS laparoscopic skills simulator. Group III practiced the same skills and, in addition, performed a simulated cholecystectomy. All students then performed a cholecystectomy in a swine model. Their performance was reviewed by two experienced surgeons. The following parameters were evaluated: Gallbladder pedicle dissection time, clipping time, time for cutting the pedicle, gallbladder removal time, total procedure time, and blood loss. RESULTS: With practice, there was improvement in most of the evaluated parameters by each of the individuals. There were no statistical differences in any of evaluated parameters between those who did and did not undergo VRSS training, however. CONCLUSION: VRSS training is assumed to be an effective tool for learning and practicing laparoscopic skills. In this study, we could not demonstrate that VRSS training resulted in improved surgical performance. It may be useful, however, in familiarizing surgeons with laparoscopic surgery. More effective methods of teaching laparoscopic skills should be evaluated to help in improving surgical performance.