Comparison of Optical Trocar Access Versus Veress Needle Insertion Technique for Peritoneal Entry in Laparoscopic Donor Nephrectomy.

BACKGROUND: Nearly half of all complications in laparoscopic surgery occur at the intraperitoneal access. We compared direct optical entry (DOE) with Veress needle entry (VNE) in terms of abdominal entry time and entry-associated complications in patients who underwent laparoscopic donor nephrectomy (LDN). METHODS: Between June 2010 and July 2023, data from 813 patients who underwent LDN were analyzed. Age, male-to-female ratio, American Society of Anesthesiologists (ASA) score, body mass index, operation side, previous abdominal surgery, abdominal entry technique, abdominal entry time, entry-associated complications, conversion to different abdominal entry techniques, and conversion to open surgery were evaluated. RESULTS: DOE and VNE were performed on 433 and 281 patients, respectively. Age (48.89 ± 12.11 vs 47.59 ± 11.34 years), male-to-female ratio (44.8% vs 40.9% males and 55.2% vs 59.1% females), ASA score (2 vs 2 median ASA score), body mass index (26.72 ± 6.11 vs 27.07 ± 5.83 kg/m2), and operation side (63.0% vs 61.3% left nephrectomy) were not statistically significant differences between the DOE and VNE groups (P > .05). However, abdominal entry time was significantly reduced in the DOE group compared with the VNE group (26.8 ± 20.8 vs 49.5 ± 34.1 seconds, P = .007, respectively). Entry-associated complications were observed in 8 (1.12%) patients. No major (grades 3-5) complications were observed. There were no statistically significant differences in overall (0.6% vs 1.7%, P = .291), grade 1, and grade 2 complication rates between the DOE and VNE groups (0.4% vs 1.4%, P = .366; 0.2% vs 0.3%, P = .714, respectively). CONCLUSIONS: DOE and VNE are not foolproof. DOE is a safe, feasible, and faster technique in patients who underwent LDN.

Partial Nephrectomy Due to Renal Cell Carcinoma in a Patient Who Was a Prior Kidney Donor: Pitfalls About Living Kidney Donation, Case Report, and Review of the Literature.

Cancer development in the remnant kidney in living kidney donors represents a challenging process in terms of patient management. Total nephrectomy is the preferred method for tumors exceeding 7 cm in size. In the case presented here, partial nephrectomy was preferred because the patient was a prior living kidney donor. On the other hand, being an organ donor always creates concerns for long-term safety and survival. The guidelines on the evaluation and care of living kidney donors have generally focused on assessment of the risk for chronic kidney disease in donors and donor-to-recipient infection or cancer transmission. In this case report, we also evaluated whether being a donor is a facilitating factor for cancer development in the remnant kidney.

The utility of intravenous ketamine for the management of intraoperative penile erection: a retrospective single-center analysis of endourological surgeries over a 4-year.

BACKGROUND: To assess the prevalence of intraoperative penile erection in our endourology practice and the utility of intravenous ketamine in the management of the condition. METHODS: Of 402 endoscopic urological procedures performed in our clinic over a 4-year (2015-2019) period, a total of 9 cases with intraoperative penile erection impeding instrumentation during endourological surgery were included. Data on patient age, weight, height, American Society of Anesthesiologists (ASA) physical status classification system scores, type and duration of surgery, type and level of anesthesia, onset of erection, treatment characteristics and treatment outcome were recorded for each patient. RESULTS: The mean (SD) age was 68.3 years (range, 66.0-77.0 years). ASA physical status category I and II were noted in 55.6 and 44.4% of patients, respectively. All cases received spinal anesthesia (n = 9) at T8-10 dermatome levels, for TURP in 7 (77.8%) cases and for TURBT in 2 (22.2%) cases. The onset of penile erection was post-urethroscope in 7 (77.8%) cases. The average total ketamine dose was 34.3 mg (range, 18.0-75.0 mg). The average duration of the operation was 91.7 min (range, 40.0-140.0 min). Ketamine treatment resulted in resolved erection with delayed procedure in 7 (77.8%) cases, while conversion to general anesthesia was required in 2 (22.5%) cases. CONCLUSIONS: In conclusion, the prevalence of intraoperative penile erection during spinal anesthesia for endourological surgery was 2.2% in our experience. These findings demonstrated that intravenous injection of ketamine is an effective and safe method for immediate resolution of intraoperative penile erection with a high success rate.

The prognostic value of routine second transurethral resection in patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer: results from randomized 10-year extension trial.

PURPOSE: To evaluate the impact of routine second TUR on the long-term outcome of patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer (NMIBC) MATERIAL AND METHODS: A total of 210 patients (mean age 62.1 years, 89.5% were males) with stage pT1 NMIBC who underwent first TUR were prospectively randomized into two groups including second TUR (n = 105) and no second TUR (n = 105) groups. Data on recurrence, disease progression, 7-year and 10-year recurrence-free survival (RFS), progression-free survival (PFS) and overall survival (OS) were recorded. RESULTS: The median follow-up time was 119 months (IQR 65-168). Per-protocol (PP) analysis revealed that compared to patients without second TUR, patients with second TUR had significantly higher 5-year, 7-year and 10-year rates for RFS (59.4%, 57.9% and 54.8% vs. 36.3%, 31.7% and 26.8%, respectively, p < 0.001) and PFS (93.3%, 91.9% and 90.4% vs. 74.0%, 71.4% and 68.5%, respectively, p < 0.001). According to PP and intention-to-treat (ITT) analyses, the 10-year OS rate was significantly higher in patients with second TUR (59.1 vs. 40.8%, p = 0.004). Multivariate analysis revealed that undergoing second TUR (OR 1.661, 95% CI 1.156-2.385, p = 0.006) was an independent determinant of prolonged OS. CONCLUSIONS: In conclusion, these findings indicate the prognostic value of second TUR in stage pT1 NMIBC patients, not only for RFS and PFS advantages but also for the long-term OS advantage. Therefore, second TUR should be routinely performed in all stage pT1 NMIBC patients with life expectancy of at least 10 years, given the positive contribution to all oncological outcomes.

Successful Endovascular Management of a Transplant Renal Artery Pseudoaneurysm Complicated With Arterioureteral Fistula.

We report a case of renal artery pseudoaneurysm at the anastomosis site complicated with arterioureteral fistula (AUF) in a 57-year-old kidney transplant recipient who presented with intermittent massive hematuria at one month post-transplant. We successfully treated the pseudoaneurysm and AUF with endovascular covered stent implantation. The diagnosis of AUF is rare and it is a condition that occurs in patients with previous pelvic or vascular surgery, chronic ureteral catheterization and radiotherapy. This diagnosis requires the expertise of the urologist, vascular surgeon and interventional radiologist. The fistula most often occur in the iliac arteries and are often associated with pseudoaneurysms or abscesses. Angiography and ureteral contrast studies (antegrade or retrograde pyelography) are the most valuable diagnostic tools. Treatment of AUF via endovascular approach using covered stents is effective and safe, and is becoming the reference treatment in AUFs.

Increasing the number of biopsies increases the concordance of Gleason scores of needle biopsies and prostatectomy specimens.

PURPOSE: To determine the importance of increasing the number of biopsy cores to decrease the discrepancy of Gleason scores of needle biopsy and radical prostatectomy specimens. MATERIALS AND METHODS: Between May 1998 and July 2005, 392 patients with clinically localized prostate cancer diagnosed by 18-gauge transrectal needle biopsy underwent radical prostatectomy. We categorized the cohort into 2 groups according to the number of the cores. Group 1 consisted of 206 patients diagnosed by extended biopsies (> or =10 cores, range 10-14, median 11). The remaining 186 patients who were diagnosed by sextant biopsies were categorized as being in group 2. Preoperative clinical variables, including patient age, digital rectal examination findings, serum prostate-specific antigen, and the number of cores positive for cancer the parameters, were assessed in both groups. The concordance of Gleason scores in both groups were analyzed by both individual Gleason scores and clinical subgroups of Gleason scores: 2-4 (well differentiated), 5-6 (moderately differentiated), 7 (intermediate), and 8-10 (poorly differentiated). RESULTS: Needle biopsies revealed moderately differentiated tumors (Gleason 5-6) for the 2 groups (55.3% and 60.2%). Gleason scores of the needle biopsies were identical to that of the prostatectomy specimen in 116 (56.31%) and 76 cases (40.86%) for each group (kappa: 0.432 and 0.216 for each group, respectively). Gleason score of the needle biopsy differed by 1 grade in 56 (27.18%) and 84 cases (45.16%), and by > or =2 units in 34 (16.50%) and 26 cases (15.05%) for each group, respectively. Of the specimens, 34% were undergraded, and 10% were overgraded in group 1. These rates were 38% and 22% in group 2, respectively. A total of 70% in group 1 and 56% in group 2 remained in the same categorical group, 28% and 32% of the specimens were undergraded, and 4% and 12% were overgraded in groups 1 and 2, respectively. In group 1, the number of patients with Gleason scores of 2-4, 5-6, 7, and 8 were 9.7%, 55.3%, 21.4%, 13.6%, and 1.9%, 47.6%, 32%, 18.4%, graded by needle biopsies and radical prostatectomy specimens, respectively. However, in the sextant group, the change was the number of patients with Gleason scores of 2-4, 5-6, 7, and 8-10 was 5.4% 60.2%, 24.7%, and 9.7%, detected by needle biopsies, respectively. Radical prostatectomy specimens revealed the same Gleason categories in 4.3%, 41.9%, 38.7%, and 15.1%, respectively. There was no correlation between categorized prostate-specific antigen levels and concordance of the Gleason grade. Age and digital rectal examination results did not affect Gleason correlation. CONCLUSIONS: We have shown that an extended biopsy scheme beyond its superior diagnostic capability also improves the concordance of Gleason scores of needle biopsies and radical prostatectomy specimens.