Perioperative, oncological, and survival outcomes of robotic radical cystectomy with urinary diversion in females: A single-center retrospective observational study.

Introduction: Robot-assisted radical cystectomy (RARC) is a standrad approach for surgical management of bladder cancer. Currently, most literature on RARC is in men, possibly due to the higher incidence of bladder cancer in males. We reviewed the perioperative, oncological and survival outcomes in 41 women who underwent RARC by a single surgeon at a tertiary health-care center. Methods: Out of 225 RARC and urinary diversion procedures performed from 2012 to 2020, a retrospective analysis of 41 women was performed. Baseline demographic and perioperative details, oncological data, and survival were recorded and analyzed. Kaplan-Meir analysis was done for survival outcomes and prognostic factors were assessed by log rank test. Results: Thirty-eight patients underwent intracorporeal urinary diversion, while three underwent extracorporeal diversion. One patient underwent organ preserving cystectomy. Clavien-Dindo 30-day postoperative complications were Grade I in 8 (19.5%), Grade II in 4 (9.8%), and Grade IIIa in 3 (7.3%) patients with no mortality. During the median follow-up of 34 months (range: 6-87 months), 7 patients died of disease recurrence. Five-year survival was 74% (95% confidence interval [CI]: 59-82) and 35% (95% CI: 10-91) in transitional cell carcinoma (TCC) and non-TCC group, respectively, with P = 0.04. There was no mortality in Stages 0 and 1 disease. Five-year survival was 78% in Stage 2 and 41% in Stage 3 and 4. Conclusion: Our study demonstrates acceptable clinical, perioperative, and oncological outcomes of robotic radical cystectomy in females, thus highlighting its safety and feasibility.

Peri-operative, Functional, Quality of Life, and Oncological Outcomes After Robot-Assisted Radical Cystectomy and Intra-corporeal Orthotopic Ileal Neobladder-Our Experience.

Robot-assisted radical cystectomy (RARC) and intracorporeal orthotopic neobladder (OINB) is technically a challenging surgery due to the involvement of prolonged console time and higher level of surgical skills. Therefore, standardizing technique and testament of good functional and oncological outcomes is required to increase its acceptance among surgeons. We report our experience of RARC with OINB and analyze the perioperative, functional, quality of life, and survival outcomes. Single surgeon experience of over 22 OINB after RARC is done, which includes 21 male and one female patients, was done retrospectively. Modified Karolinska Studer technique of neobladder creation was followed. Intraoperative findings, post-operative complications, and follow-up information were recorded for analysis. The patients' median age was 50.5 years (IQR, 41.25-55.50), and the median follow-up period was 45.5 months (IQR, 26.75-68). Median console time was 447.5 min (IQR, 347.5-500), blood loss was 225 ml (IQR, 200-250), and hospital stay was 12 days (IQR, 11-15). Most of the complications were Clavien-Dindo grades I and II. Longer surgery time and more complications were noted in the first 10 cases compared to the next 12 cases. Day and night-time urinary continence is 95% and 77% at 12 months, respectively. Two patients died of disease, and overall survival at 5 years was 84%. Our experience supports OINB as a feasible option after RCIC with acceptable complications, good functional and survival outcomes, with better quality of life. With experience, surgical morbidity and operative time decrease. This surgery should be undertaken after gaining experience with an intracorporeal ileal conduit and has a steep learning curve.

Role of interventional radiology in the management of complex pediatric surgical cases.

INTRODUCTION: Minimally-invasive techniques offered by interventional radiology (IR) are really helpful in the management of challenging surgical cases. The current report highlights a series of four complex pediatric surgical cases which were successfully managed by specific image-guided techniques. CASE PRESENTATION: The first two cases in the present report were infants. One of them had a complicated type-1 choledochal cyst (obstructive jaundice and cholangitis) and was optimized with preoperative percutaneous transhepatic biliary drainage (PTBD) under fluoroscopic guidance. The other child had bilateral ureteropelvic junction obstruction and presented with urosepsis. Due to failure of retrograde stenting on one side, image-guided percutaneous nephrostomy and antegrade stenting were performed. The third and fourth cases had suffered blunt trauma to the abdomen. While one of them developed multiple pseudoaneurysms and arterioportal fistulae in the liver, the other had transection of the right posterior sectoral duct. Angioembolization of the pseudoaneurysms and embolization of the right posterior sectoral duct were performed for them under image-guidance respectively. The post-procedural course of all the above children was uneventful. DISCUSSION: Image-guided minimally invasive procedures are associated with less post-procedural pain, early recovery, and better cosmetic outcomes. In specific scenarios, they may even obviate the need for surgical intervention, thereby reducing the overall morbidity. CONCLUSION: Interventional radiology offers safe and effective alternatives to operative interventions. They are especially useful in the backdrop of significant morbidities like cholangitis, urosepsis, and trauma.

Congenital extrahepatic portocaval malformation: Rare but potentially treatable cause of pulmonary hypertension.

OBJECTIVE: Abernethy malformation (congenital extrahepatic portosystemic shunt) is a rare anomaly of the splanchnic venous system. Though rare, it is an important cause of pulmonary artery hypertension (PAH) which is often missed. All patients with PAH should be carefully evaluated for presence of Abernethy malformation before labelling them as Idiopathic PAH. METHODS: This is a retrospective analysis of prospectively collected data. We reviewed the data of all patients referred to our center for evaluation of PAH. 10 patients were diagnosed to have an extrahepatic portocaval malformation. We reviewed their presentation, diagnosis, catheterization data, intervention and their outcome along with review of literature. RESULTS: 10/104 patients with pulmonary hypertension and no intra or extracardiac shunt were found to have extrahepatic portocaval shunt (EHPCS). 3 patients had EHPCS type 1 and 7 had type 2 EHPCS. 6/7 patient with EHPCS type 2 underwent closure of the shunt. There was no procedure related complication. There was one death 3 months post procedure and one patient who was advised surgical closure was lost to follow up. Closure of the shunt resulted in normalization of the pulmonary artery pressures in 4/5 patients. CONCLUSION: Congenital portosystemic malformations form an important and potentially treatable cause of pulmonary hypertension.

Comparative study of perioperative and survival outcomes after video endoscopic inguinal lymphadenectomy (VEIL) and open inguinal lymph node dissection (O-ILND) in the management of inguinal lymph nodes in carcinoma of the penis.

Open inguinal lymph node dissection (O-ILND) is the gold standard in the management of lymph nodes in carcinoma penis; however, video endoscopic inguinal lymphadenectomy (VEIL) is performed in some centers. Our primary objective is to compare perioperative and survival outcomes in patients undergoing VEIL with O-ILND, as very few studies have reported long-term survival outcomes till date. We analyzed patients who underwent O-ILND and VEIL (laparoscopic or robot-assisted) from January 2009 to January 2020 in our institute for carcinoma of the penis. Patient details, perioperative complications, and survival outcomes were analyzed. Perioperative outcomes were analyzed by logistic regression and survival outcomes by log-rank and Cox regression methods. We analyzed 79 patients (32 O-ILND, 47 VEIL) with a median follow-up of 51 (IQR 25.5-75.5) and 42 months (IQR 21-62). Wound complications were common in O-ILND group (65.6%) compared to VEIL group (27.7%) (p = 0.001), predominantly skin flap necrosis in 14 groins (23.73%) after O-ILND and none after VEIL. Median overall survival was 80 and 88 months (p = 0.840) with five-year survival of 65% and 66.8% (p = 0.636) and five-year DSS of 76.6% and 73.9% (p = 0.96) in O-ILND and VEIL, respectively. Multivariate analysis showed that grade and pathological node status were significant (HR-2.650, p = 0.040; HR-3.218, p = 0.024) factors for survival. The retrospective nature of the study design is the limitation. Management of inguinal lymph nodes in carcinoma penis by VEIL is safe, associated with lesser wound-related complications, and equivalent survival outcomes compared to O-ILND. It should be considered as an alternative option for inguinal lymph node dissection.

18F-FDG PET/CT-directed biopsy: does it offer incremental benefit?

PURPOSE: To study whether the metabolic information provided by a prior PET/computed tomography (CT) scan can add valuable information and an incremental benefit while performing image-guided biopsies. METHODS: Fluorine-18 fluorodeoxyglucose (F-FDG) PET/CT findings of 112 patients were available before biopsy and were considered for analysis. Biopsies were performed using standard techniques only after the needle tip was confirmed to be in the portion of the lesion corresponding to the hypermetabolic area seen on PET. This was achieved by visual coregistration and also by software registration algorithms that registered the intraprocedural CT images with the preselected PET/CT data. Only those biopsies for which a definitive histopathological diagnosis could be made were considered 'diagnostic'. Cases in which PET/CT added an incremental value were divided into three categories. RESULTS: A total of 112 patients (66 male and 46 female, age range 16-74 years) underwent a biopsy based on PET findings. The biopsy sites were as follows: lung, 54; lymph nodes, 27; bone, 12; and soft-tissue masses/deposits, 19. Out of the 112 biopsies, an incremental benefit was seen overall in 53 patients (47.3%): in 40.7% (22/54) of patients who underwent lung biopsies, 44.4% (12/27) of those who underwent lymph node biopsies, 66.6% (8/12) of those who underwent bone biopsies and 57.8% (11/19) of those who underwent soft-tissue biopsies. Out of the cases that showed an incremental benefit, the highest number (30) belonged to the category in which the biopsy sample was obtained from the focal hypermetabolic portion of the apparently larger morphological lesion seen on CT. CONCLUSION: PET/CT data coregistered with intraprocedural CT images can guide needle placement in the viable portion of the lesion, thus increasing the chances of achieving a definitive diagnosis. This approach can offer a significant incremental benefit while performing image-guided biopsies.

Percutaneous computed tomography-guided core biopsy for the diagnosis of mediastinal masses.

AIM: To describe various approaches of computed tomography (CT)-guided core biopsy and evaluate its ability to obtain adequate tissue for the assessment of mediastinal masses. MATERIALS AND METHODS: Between February 2004 and October 2006, 83 percutaneous CT-guided biopsies of mediastinal lesions were performed on 82 patients under local anesthesia. Coaxial needles were used and minimum of 3-4 cores were obtained. Post-biopsy CT scan was performed and patients observed for any complications. Tissue samples were taken to Pathology Department in formalin solution. RESULTS: From the 83 biopsies, adequate tissue for histological diagnosis was obtained in 80 (96%), and the biopsy was considered diagnostic. Of the 80 diagnostic biopsies, 74 biopsy samples were definitive for neoplastic pathology and 6 biopsy samples revealed no evidence of malignancy. There were no major complications. Minor complications were recorded in 5 patients. CONCLUSION: Percutaneous image-guided core biopsy of mediastinal lesions is an accurate, safe and cost-effective tool for the initial assessment of patients with mediastinal masses.