Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database.

Introduction: There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN. Methods: For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers. Results: In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively. Conclusions: This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

The impact of transition from conventional robot-assisted radical prostatectomy to retzius sparing robot-assisted radical prostatectomy: A retrospective multivariate analysis.

INTRODUCTION: To assess the outcomes of Retzius sparing robotic-assisted radical prostatectomy (RS-RARP) in comparison with the conventional RARP. MATERIALS AND METHODS: A retrospective analysis of 320 cases of RARP, performed from 2014 April to 2019 April, was performed. The predictor variables included age, body mass index, clinical stage, prostate-specific antigen, Gleason score category in biopsy, D'Amico risk category, presence of the median lobe, prior transurethral resection of the prostate, and the ability to perform the RS-RARP. The outcome variables included console time, blood loss, blood transfusion, nerve sparing, bladder neck sparing, positive surgical margins (PSM), number and the site of PSMs, extracapsular invasion, seminal vesicle involvement, complications, continence, erectile function, biochemical recurrence, and adjuvant treatment. Regression analysis was performed using the linear regression for the continuous variables and binary logistic regression for the categorical variables with two levels. RESULTS: Three hundred and twenty patients underwent radical prostatectomy from 2014 April to 2019 April. We started the RS-RARP program in December 2016. Twenty-three patients who did not meet the inclusion criteria were excluded and a total of 297 patients were studied. Multivariate analysis demonstrated that RS-RARP was a strong positive independent predictor for continence recovery at 3 months, 6 months, and 12 months. RS-RARP was an independent predictor of reduced console time and increased probability of bladder neck sparing. RS-RARP was also independently associated with increased PSM in the posterolateral, anterolateral, and the apical regions. CONCLUSION: RS-RARP has better continence rates up to 12 months compared with the conventional approach, but is associated with increased PSM at certain locations.

Robotic-assisted dual kidney transplantation.

AIM: The aim of this study was to report the feasibility of robotic-assisted dual kidney transplantation (DKT) in a marginal donor. MATERIALS AND METHODS: The case was a 53-year-old male, who with IgA nephropathy underwent a robotic-assisted robotic DKT. RESULTS: The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the 1st day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2. CONCLUSION: Robotic DKT offers solutions to the challenges faced in open DKT.

Renal transplantation through a modified non-muscle-cutting Pfannenstiel incision.

AIM: To assess the feasibility of performing a renal transplant operation through a modified non-muscle-cutting Pfannenstiel incision (MFI). MATERIALS AND METHODS: Renal transplantation with MFI was performed in 20 men with a body mass index (BMI) of less than 25 and five women with a BMI of less than 27. The parameters assessed were incision length, operative time, postoperative pain score by visual analogue score, wound complication, graft-related complications, eGFR at 3 months, and surgical scar satisfaction score. The results were compared with a BMI-matched cohort of patients who had a conventional hockey stick incision. Statistical analyses were done by Chi-square test and Student's t test. RESULTS: There was a significant decrease in mean bed preparation time, mean time for closure, and mean incision length in patients with MFI. In MFI group, the mean surgical satisfaction score was significantly more. There was no significant difference between the groups on all other aspects. CONCLUSION: In the era of minimally invasive surgery, MFI technique could challenge the role of laparoscopic and robotic surgery in renal transplantation. Our study shows that the technique is successful in carefully selected patients with low BMI.

Laparoscopic donor nephrectomy with transvaginal extraction: initial experience of 30 cases.

PURPOSE: To assess the safety and feasibility of laparoscopic donor nephrectomy with transvaginal extraction and impact of body mass index (BMI), menopausal status, previous surgery, and uterine fibroids. PATIENTS AND METHODS: Five-port conventional laparoscopic donor nephrectomy with successful transvaginal extraction of the kidney was performed in 30 donors. The parameters assessed included age, BMI, operative time, estimated blood loss, warm ischemia time, postoperative pain score, preoperative and postoperative sexual function, wound complications, hospital stay, return to normal activities, recipient creatinine level, and other recipient-related complications. The data were compared with 30 female donors who had laparoscopic donor nephrectomy and transabdominal extraction. RESULTS: The total number of patients who consented for the study was 38. In seven patients, an intraoperative decision to abort the transvaginal extraction was made because of obesity, pelvic adhesions, large uterine fibroids, and uterine artery injury. When compared with transabdominal extraction, there was no significant difference in warm ischemia time, mean operative time, estimated blood loss, hospital stay, recipient creatinine level, and complications. The mean pain score was significantly less on postoperative day 3 and day 4. There was also an earlier return to normal activities in the transvaginal group. There was no increase in infectious complication in both donors and recipient. CONCLUSION: Based on our initial experience with laparoscopic donor nephrectomy with transvaginal extraction, we recommend this procedure for a premenopausal donor, with a BMI <30. Our initial cases demonstrate that transvaginal extraction is feasible and safe for the donors.

A rare case of prostatic malignancy.

A 70-year-old male presented with refractory urinary retention 3 years back. He had undergone a prior trans urethral resection of prostate (TURP) 5 months back elsewhere. A revision TURP was done and the histopathology showed differentiated adenocarcinoma with cartilaginous and osseous metaplasia. Bone scan showed no evidence of metastasis. He underwent bilateral orchidectomy soon after. He presented with urinary retention 14 months later and underwent TURP. Hard prostatic tissue was resected and histopathology reports were same as previous report. Bone scan showed evidence of solitary metastasis in the second rib. MRI and CT scan showed re-growth. He had persisting lower urinary tract symptoms with hematuria. A palliative radiation was given which alleviated the urinary symptoms; patient refused radical cystoprostatectomy and currently is on conservative management.

Robotic-assisted radical cystectomy and orthotopic ileal neobladder using a modified Pfannenstiel incision.

OBJECTIVES: To report our technique of robotic-assisted laparoscopic radical cystectomy with a modified Pfannenstiel incision. Robotic-assisted laparoscopic radical cystectomy has been gaining in popularity. A completely intracorporeal procedure is a technically difficult and time-consuming procedure. Most surgeons perform the diversion using a small incision, typically midline, that is also used for specimen retrieval. METHODS: Radical cystectomy and pelvic lymph node dissection was performed using a da Vinci robotic platform in a standard fashion. The robot was undocked and an 8-10 cm modified Pfannenstiel incision made. A self-retaining retractor was used to expose the wound. The specimen was extracted, and an ileal neobladder was reconstructed using the incision. RESULTS: We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). The mean estimated blood loss was 310 ± 220 mL, and the mean operating time was 6 ± 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. The mean number of lymph nodes removed was 12 ± 3. The mean hospital stay was 8.5 days. CONCLUSIONS: Our initial experience with our technique of robotic-assisted laparoscopic radical cystectomy and neobladder construction using a modified Pfannenstiel incision has been favorable. The incision provides good exposure, facilitating neobladder reconstruction, can be used for specimen retrieval, and heals better with a cosmetic scar.

Lymphovascular invasion in radical cystectomy specimen: is it an independent prognostic factor in patients without lymph node metastases?

PURPOSE: To determine the prognostic significance of lymphovascular invasion (LVI) in patients with urothelial carcinoma of the bladder undergoing radical cystectomy (RC) and bilateral pelvic lymph node dissection. METHODS: From 1992 to 2008, 526 patients underwent RC and pelvic lymphadenectomy at our institution by a single surgical team. All relevant data were entered into a database and analyzed. LVI was defined as "the presence of tumor cells within an endothelial lined space." The exclusion criteria were non-TCC histology, salvage cystectomy, neoadjuvant chemotherapy, and unknown LVI status. RESULTS: A total of 357 patients met the inclusion criteria. Overall prevalence of LVI was 29%. LVI was significantly associated with higher T stage, lymph node (LN) metastases, and higher grade. Patients with LVI had significantly higher recurrence rate (P < 0.001) and decreased long-term survival (P < 0.001). In patients without LN metastases, LVI in the primary led to a significantly decreased recurrence-free (P = 0.003) and disease-specific survival (P = 0.001). In the presence of LN metastases, LVI did not significantly alter the recurrence-free or disease-specific survival. On multivariate analysis, T stage (P < 0.0001) and LN metastases (P = 0.01) were significant independent prognostic factors influencing disease-specific survival. LVI did not have independent prognostic value. T stage was the only significant prognostic factor in the lymph node negative group. CONCLUSIONS: Although, the presence of LVI in node-negative patients is an adverse prognostic factor on univariate analysis of disease-specific survival, it is not an independent prognostic factor on multivariate analysis. Pathological stage is the only independent prognostic factor for survival.

The risk and prophylactic management of bladder cancer after various forms of radiotherapy.

PURPOSE OF REVIEW: Prostate cancer is the most common cancer diagnosed in men and remains the second most lethal malignancy. Most patients undergoing treatment elect for radical prostatectomy or radiation. As the number of patients treated has increased and survival improved, delayed complications of these modalities has assumed increased importance. Recent studies report an increased risk of certain cancers after radiation for prostate cancer. This review aims to summarize recent data. RECENT FINDINGS: Recent studies have confirmed the association of prostate radiation with secondary cancers. The most common secondary malignancy is bladder carcinoma. We have treated 44 patients with bladder cancer who had radiation therapy for prostate cancer. At diagnosis, 60% had tumor, which invaded the bladder muscle (T2 or greater disease). The mean latency from radiation to diagnosis of bladder cancer was 5.5 years. SUMMARY: Radiation therapy for prostate cancer is associated with an increased risk of bladder cancer. In our series, patients presented at higher stage than expected from population-based studies of bladder cancer. Patients and their physicians should be aware of such risks when choosing therapy for prostate cancer. Hematuria following radiation therapy for prostate cancer should be investigated rather than being attributed to radiation-induced cystitis.

Comparative analysis of lighted ureteral stents: lumination and tissue effects.

PURPOSE: The objectives of the present study were to compare the luminescence of three types of ureteral illuminated stents and analyze their effects on urothelial histology. MATERIALS AND METHODS: Three types of illuminating ureteral stents; the Cook single illuminating catheter, Cook double illuminating catheter and Stryker illumination system stent were laparoscopically placed in nine female white pigs (50 kg), under general anesthesia. After leaving the stents illuminated for 3 hours, during which time peritoneal insufflation was maintained at 18 mm Hg, the ureter was transected and the intraluminal temperature of the ureter was measured with a digital thermometer. The ureteral tissue was then harvested for histologic evaluation, and the animal was euthanized. RESULTS: Statistical analysis confirmed that Stryker and Cook double illuminated stents were equally efficient in illuminating the ureter (P 0.46) whereas, the Cook single stent was significantly superior (P = 0.000004). There was no significant difference in mean intraluminal temperatures between the Cook single (95.2 degrees F), Cook double (92.3 degrees F), and Stryker (95.1 degrees F) stents. When compared with the intraluminal temperature of control unstented ureters, no significant increase was noted with the Cook single (P = 0.85), Cook double (P = 0.57), or Stryker (P = 0.82). Histologic analysis did not show any evidence of thermal injury to the urothelium or any remarkable alteration in the ureteral mucosa. CONCLUSION: The Cook single illuminated stent presented the highest luminescence. All three devices did not cause any remarkable injury to the urothelium after 3 hours of exposure.

Estimation of size of distal ureteral stones: noncontrast CT scan versus actual size.

OBJECTIVES: To determine the accuracy of stone size determination by computed tomography (CT) for distal ureteral calculi. METHODS: A total of 76 patients who presented with distal ureteral stone were evaluated with CT. Of the 76 patients, 41 successfully passed the stone spontaneously and intact. The largest stone size dimension measured on CT by an experienced endourologist was compared with the actual measured size of the spontaneously expulsed stone as measured by digital calipers. RESULTS: The mean actual size of the stone was 4.51 mm (range 1-9.2, SD +/- 1.91). The mean largest dimension measured on CT was 5.51 mm (range 2-11.2, SD +/- 2.09). The correlation coefficient (r) when comparing the actual size with the CT scan measurement was -0.022. When the largest stone dimension was obtained on the craniocaudal CT images, the correlation coefficient was 0.097. When the largest stone dimension was obtained on the axial CT image, the correlation coefficient was -0.107. CONCLUSIONS: CT scan imaging is a poor predictor of the largest stone dimension for distal ureteral calculi. Caution should be used in counseling patients on the rate of spontaneous stone passage when determined using CT measurements of stone size.

Early laparoscopic repair for supratrigonal vesicovaginal fistula.

Laparoscopic repair of supratrigonal vesicovaginal fistula is less morbid and equally effective compared to open repair. This approach is advisable when transvaginal repair is difficult.

Virtual cystoscopy by intravesical instillation of dilute contrast medium: preliminary experience.

PURPOSE: We determined whether virtual cystoscopy based on helical data sets can yield urinary capabilities similar to those achieved by fiber-optic cystoscopy. MATERIALS AND METHODS: A total of 11 patients with ultrasound detected bladder tumors underwent pelvic CT as a single volumetric scan after preliminary bladder distention with saline mixed with contrast medium using a 6Fr infant feeding tube. Cystoscopy was simulated based on a 3-dimensional helical CT data set in real time. Source raw CT data for virtual cystoscopy were reconstructed and navigation was done in real time using surface rendering navigation software. These images and findings were then compared with conventional cystoscopy findings. RESULTS: An attenuation gradient of 350 HU between the vesical mucosa and urine was noted. Two of the 14 tumors (11 patients) were missed and each was 0.7 cm. All tumors greater than 0.9 cm were detected. Overall sensitivity was 85.7%. There were no false-positive findings. There was good correlation with tumor location and size. The ureteral orifices and their relationship to the tumor were also well appreciated. Subtle mucosal changes on conventional cystoscopy were not delineated by virtual cystoscopy. CONCLUSIONS: Our method of instilling dilute contrast medium in the bladder offers an excellent attenuation gradient. The overall sensitivity of tumor detection is better than that reported for intravenous contrast medium and pneumocystoscopy.

Transperitoneal laparoscopic approach for retrocaval ureter.

We had a 14 year old boy, who presented with recurrent attacks of right loin pain. Investigations revealed a retrocaval ureter. A transperitoneal three port laparoscopic approach was undertaken. The retrocaval portion of ureter was excised. A double J stent was placed laparoscopically and ureteroureterostomy was done with intracorporeal suturing. The patient was discharged after 72 hours and the stent was removed on the 15(th) day. Follow up showed regression of hydronephrosis. We recommend this approach compared to open surgery, as it offers several advantages compared to conventional open surgery like decreased postoperative pain, decreased hospital stay and a cosmetically more acceptable surgical scar.

Vesicocutaneous fistula arising from a bladder diverticulum.

A 55-year-old man presented with intermittent episodes of urinary leak through the left groin following an abscess drainage at that site at the age of 5 years. Since then he had been suffering from recurrent urinary tract infections and urinary leak, which used to be treated symptomatically. Intravenous urogram (IVU), voiding cystourethrogram (VCU), and cystoscopy done in our institution revealed a bladder diverticulum with a stone in situ, which was communicating with the fistulous opening located in the left groin. Diverticulectomy and excision of the fistulous tract cured the patient. A long-standing fistula arising from a bladder diverticulum at relatively distant site is of extreme rarity. Vesicocutaneous fistula from an iatrogenic injury to vesical diverticulum resulting from a groin surgery has not been reported so far.