Impact of learning curve on the perioperative outcomes following robot-assisted partial nephrectomy for renal tumors.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive technique to treat patients with renal masses. The aim of this study was to assess the learning curve (LC) of RAPN, evaluate its impact on perioperative outcomes following RAPN and to study the role of surgeon experience in achieving "trifecta" outcomes following RAPN. METHODS: We prospectively analyzed the clinical and pathological outcomes of 108 consecutive patients who underwent RAPN for renal tumors from January 2012 to December 2016 by a laparoscopy trained surgeon with no prior robotic experience. We used warm ischemia time (WIT) <20 min, operative time <120 min, and blood loss <100 ml as endpoints for plotting the LCs. Trifecta was analyzed in relation to our LC. RESULTS: Surgeon experience was found to correlate with WIT, operative time, and blood loss. Overall 18.5% of patients developed complications. Complication rate reduced with increasing surgeon experience. LC was 44 cases for WIT ≤20 min, 44 cases for operative time <120 min, and 54 cases for blood loss <100 ml. Trifecta outcome was achieved in 67.6% patients overall and was found to correlate with increasing surgeon experience. Improvement in trifecta outcomes continued to occur beyond the LC. CONCLUSIONS: RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. For a surgeon trained in laparoscopy, acceptable perioperative outcomes following RAPN can be achieved after an LC of about 44 cases. Increasing surgeon experience was associated with improved "trifecta" achievement following RAPN.

Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique.

OBJECTIVE: Circumcision, by most conventional methodologies, involves division of the frenulum and excision of the entire foreskin covering the glans. This seemingly simple procedure is occasionally associated with dreadful and devastating complications. We describe a new frenulum-sparing technique that circumvents some of the potential complications of conventional techniques and could also potentially help preserve preputial role in sexual function. MATERIALS AND METHODS: An initial dorsal slit, three fourths of the way up to the corona is extended laterally and obliquely on either side, to meet the preputial edge, 3-4 mm from the frenulum. A broad sleeve of sub-coronal mucosa is thus preserved. The frenulum is left untouched, leaving a wide skin bridge connecting the mucosal sleeve with the shaft skin. The raw area is closed with interrupted, synthetic absorbable sutures. Over a three year period, 42 patients were circumcised using this technique. RESULTS: No significant complications like frenular bleed, painful postoperative erections, chordee, meatal stenosis, or urethra-cutaneous fistula were observed in any patient. The cosmetic results were pleasing. CONCLUSION: The frenulum-sparing technique of circumcision is a promising modification to the various existing techniques. The method described is technically easier to perform than conventional frenulum-dividing procedures and has an acceptable cosmesis. Further randomised controlled studies on larger cohorts are necessary to establish the true benefits of this technique over established procedures.

Wrong site surgery! How can we stop it?

INTRODUCTION: "Primum non nocere" (first do no harm): Hippocrates (c. 460 BC-377 BC). Wrong site surgery is the fourth commonest sentinel event after patient suicide, operative and post-operative complications, and medication errors. Misinterpretation of the clinic letters or radiology reports is the commonest reason for the wrong site being marked before surgery. MATERIALS AND METHODS: We analyzed 50 cases each of operations carried out on the kidney, ureter, and the testis. The side mentioned on clinic letters, the consent form, and radiology reports lists were also studied. The results were analyzed in detail to determine where the potential pitfalls were likely to arise. RESULTS: A total of 803 clinic letters from 150 cases were reviewed. The side of disease was not documented in 8.71% and five patients had the wrong side mentioned in one of their clinic letters. In the radiology reports, the side was not mentioned in three cases and it was reported wrongly in two patients. No wrong side was ever consented for and no wrong side surgery was performed. CONCLUSION: The side of surgery was not always indicated in clinic letter, theatre list, or the consent form despite the procedure being carried on a bilateral organ. As misinterpretation is a major cause of wrong side surgery, it is prudent that the side is mentioned every time in every clinic letter, consent form, and on the theatre list. The WHO surgical safety checklist has already been very effective in minimizing the wrong site surgery in the National Health Service.

Fundamental skills of robotic surgery: a multi-institutional randomized controlled trial for validation of a simulation-based curriculum.

OBJECTIVE: To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS). METHODS: FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group. RESULTS: Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively). CONCLUSION: FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills.

Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

OBJECTIVE: To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Balloon of a Foley catheter inflated in the bulbar urethra. Fourth arm cranial traction via suture in the tip of the catheter. DVC oversewn under direct vision. RESULTS: Oversew of DVC with minimal patient-side surgical assistance. About a 50% reduction in apical positive margin rate. CONCLUSION: A useful, ergonomic method of oversewing the DVC during RALP.

Occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS): a novel technique demonstrating segmental renal blood supply to assist zero-ischaemia robot-assisted partial nephrectomy.

BACKGROUND: Recent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time. OBJECTIVE: To describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: We used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. SURGICAL PROCEDURE: We used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We prospectively collected data on baseline, perioperative, and postoperative parameters. RESULTS AND LIMITATIONS: We describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36-85), and the mean tumour size was 29.6mm (range: 20-42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12-30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200-1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0-24). The mean follow-up was 6.4 mo (range: 5-8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins. CONCLUSIONS: Intraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.

An unusual case of S-shaped malformation of the ipsilateral kidney with normal contralateral kidney.

Crossed ectopia is a rare congenital anomaly. S-shaped (sigmoid) kidney is one of the varieties of crossed ectopia that is associated with absence of any renal tissue in the contralateral renal fossa. S-shaped malformation of an ipsilateral kidney with presence of the contralateral kidney is an extremely rare condition and, to our knowledge, has been described only once before in the literature. We present the case and discuss the hypothesis for this rare malformation.

Status of Robot-Assisted Radical Cystectomy (RARC) in 2012.

Robot-assisted radical cystectomy (RARC) for bladder cancer is increasingly becoming popular in specialist centres around the world. RARC has the advantage of being minimally invasive and also the dexterity of the instruments allow reconstruction such as ileal conduit urinary diversion or neobladder formation. Starting from the initial series demonstrating the feasibility of RARC and extended pelvic lymph node dissection, we now have mature series demonstrating equal oncological and functional outcomes in the medium term follow-up. In addition, literature suggests decreased hospital stay, less blood loss equating to less blood transfusion and a trend towards decreased complications as well. In the near future we would anticipate further refinement and reduced operating times with increased benefits for the patient undergoing RARC.

Segmental testicular infarction following cysto-prostatectomy.

Segmental (partial) testicular infarction is a very rare condition of unknown cause in more than 70% of cases. Several predisposing conditions have been described, but to our knowledge, this is the first documented case and often overlooked complication occurring as a result of cysto-prostatectomy. It usually presents in an acute manner resembling testicular torsion or epididymo-orchitis and is confirmed using ultrasonography. In some cases, it may present insidiously with no pain and may be confused with a testicular tumor due to the hypo-echoic features on imaging. In unclear situations, Doppler sonography shows vascularity and a magnetic resonance scan can be useful to distinguish between the two conditions.

The unusual history and the urological applications of botulinum neurotoxin.

INTRODUCTION: Botulinum neurotoxin (BoNT) is probably the most potent biological toxin that can affect humans. Since its discovery by Justinus Kerner, BoNT has seen use in a wide range of cosmetic and non-cosmetic conditions such as cervical dystonia, cerebral palsy, migraines and hyperhidrosis. We tried to trace its history from its inception to its recent urological applications. MATERIALS AND METHODS: Historical articles about botulinum toxin were reviewed and a Medline search was performed for its urological utility. We hereby present a brief review of historical aspects of BoNT and its applications in urology. RESULTS: In 1793, the first known outbreak of botulism occurred due to 'spoiled' sausage in Wildebad, Germany. The German physician and poet Justinus Kerner published the first accurate description of the clinical symptoms of botulism (sausage poison). He was also the first to mention its potential therapeutic applications. In urology, BoNT has been used in bladder and urethral lesions with varying degree of success. Recently, BoNT applications were explained for prostatic disorders. BoNT applications in urology are in the treatment of detrusor external sphincter dyssynergia, detrusor overactivity, detrusor underactivity, spastic conditions of the urethral sphincter, chronic prostate pain, interstitial cystitis, non-fibrotic bladder outflow obstruction (including benign prostatic hyperplasia) and acute urinary retention in women. CONCLUSION: Justinus Kerner is the godfather of botulism research. The role of BoNT in urology has evolved exponentially and it is widely used as an adjuvant in voiding dysfunction. In the future, its utility will broaden and guide the urologist in managing various urological disorders.

Raman spectroscopy and its urological applications.

PURPOSE: The Raman spectroscopic technology can be utilized for the detection of changes occurring at the molecular level during the pathological transformation of the tissue. The potential of its use in urology is still in its infancy and increasing utility of this technology will transform noninvasive tissue diagnosis. The Nobel laureate, Sir C.V. Raman is credited for the discovery of the principles of Raman spectroscopy. MATERIALS AND METHODS: Applications of Raman spectroscopy in the bladder, renal, prostate, and other urological disorders were gathered from Medline and abstracts from recent international urological meetings. Current status and future directions of Raman spectroscopy in urology were also reviewed. RESULTS: Raman spectroscopic technology is used to interrogate biological tissues. The potential use of this technology in urology has shown encouraging results in the in vitro diagnosis and grading of cancers of the bladder and the prostate. Raman microprobes have been used for the characterization and identification of renal lithiasis. Technology may be available for the urologists to determine the margin status intraoperatively during partial nephrectomy and radical prostatectomy. The future would see the development of optical fiber probes to incorporate them into catheters, endoscopes, and laparoscopes that will enable the urologist to obtain information during the operation. CONCLUSION: Raman spectroscopy is an exciting tool for real-time diagnosis and in vivo evaluation of living tissue. The potential applications of Raman spectroscopy may herald a new future in the management of various malignant, premalignant, and other benign conditions in urology.

The discovery of prostate-specific antigen.

The discovery of prostate-specific antigen (PSA) was beset with controversy; as PSA is present in prostatic tissue and semen, it was independently discovered and given different names, thus adding to the controversy. In this review we document the early research in this field to describe the chronology of the discovery of PSA. Using a comprehensive Medline search of the historical aspects of PSA, all relevant papers were reviewed; communication with the scientists involved in the discovery of PSA was an invaluable contribution. In 1960, Flocks was the first to experiment with antigens in the prostate and 10 years later Ablin reported the presence of precipitation antigens in the prostate. In 1971, Hara characterized a unique protein in the semen fluid, gamma-seminoprotein. Li and Beling, in 1973, isolated a protein, E1, from human semen in an attempt to find a novel method to achieve fertility control. In 1978, Sensabaugh identified semen-specific protein p30, but proved that it was similar to E1 protein, and that prostate was the source. In 1979, Wang purified a tissue-specific antigen from the prostate ('prostate antigen'). PSA was first measured quantitatively in the blood by Papsidero in 1980, and Stamey carried out the initial work on the clinical use of PSA as a marker of prostate cancer. Thus the discovery of PSA is interesting and surrounded by controversy. Although the credit for purifying PSA goes to Wang, other eminent scientists published research on this antigen. The initial work on PSA in semen was to asses its properties as a forensic marker for rape victims, but soon its potential as a marker for prostate cancer became evident.

Disappearing drain--disaster averted and lesson learnt!

The use of postoperative drains date back to Hippocrates. We report an iatrogenic case of migrated drain into the retroperitoneum. A novel technique using a rigid cystoscope for retrieval is described that prevented another laparotomy.