Best practices in near-infrared fluorescence imaging with indocyanine green (NIRF/ICG)-guided robotic urologic surgery: a systematic review-based expert consensus.

PURPOSE: The aim of the present study is to investigate the impact of the near-infrared (NIRF) technology with indocyanine green (ICG) in robotic urologic surgery by performing a systematic literature review and to provide evidence-based expert recommendations on best practices in this field. METHODS: All English language publications on NIRF/ICG-guided robotic urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus® and Web of Science™ databases (up to April 2019). Experts in the field provided detailed pictures and intraoperative video-clips of different NIRF/ICG-guided robotic surgeries with recommendations for each procedure. A unique QRcode was generated and linked to each underlying video-clip. This new exclusive feature makes the present the first "dynamic paper" that merges text and figure description with their own video providing readers an innovative, immersive, high-quality and user-friendly experience. RESULTS: Our electronic search identified a total of 576 papers. Of these, 36 studies included in the present systematic review reporting the use of NIRF/ICG in robotic partial nephrectomy (n = 13), robotic radical prostatectomy and lymphadenectomy (n = 7), robotic ureteral re-implantation and reconstruction (n = 5), robotic adrenalectomy (n = 4), robotic radical cystectomy (n = 3), penectomy and robotic inguinal lymphadenectomy (n = 2), robotic simple prostatectomy (n = 1), robotic kidney transplantation (n = 1) and robotic sacrocolpopexy (n = 1). CONCLUSION: NIRF/ICG technology has now emerged as a safe, feasible and useful tool that may facilitate urologic robotic surgery. It has been shown to improve the identification of key anatomical landmarks and pathological structures for oncological and non-oncological procedures. Level of evidence is predominantly low. Larger series with longer follow-up are needed, especially in assessing the quality of the nodal dissection and the feasibility of the identification of sentinel nodes and the impact of these novel technologies on long-term oncological and functional outcomes.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure.

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

Robotic uterine-sparing vesicovaginal fistula repair.

INTRODUCTION AND HYPOTHESIS: The objective was to describe a technique for the robotic repair of complex vesicovaginal fistula (VVF) with uterine preservation. METHODS: From 2015 to 2017, two patients underwent the procedure. Following placement of the patient in the lithotomy position, catheterization of the fistulous tract and laparoscopic omental harvesting is performed. Then, the robotic system is docked. A transverse incision was made in the peritoneum above the uterus was made to provide access to the bladder, the uterus is mobilized, and a cystotomy is performed to identify the structures. Subsequently, the cystotomy is extended toward the fistulous tract, the plane between the organs is dissected to proceed with the vaginal closure, the vagina is closed, the omental flap is interposed, and the bladder is closed. RESULTS: Mean operative time (OT) was 219 min. Mean estimated blood loss (EBL) was 75 ml. One of the patients had an intraoperative cervix canal injury that was identified and repaired. The postoperative course was uneventful, and the mean length of hospital stay (LOS) was 1 day. A mean follow-up of 17 (±9.89) months showed no recurrence at cystoscopy or imaging evaluation. CONCLUSIONS: Uterine-sparing VVF repair is feasible and safe. More studies are needed to assess equivalence compared with other procedures.

Treatment of Acute Myeloid Leukemia with the FLT3 Gene Mutation.

In acute myeloid leukemia (AML), mutations of the Fms-like tyrosine kinase 3 receptor (FLT3) and its overexpression are related with hyperleukocytosis, higher risk of relapse, and decrease of both disease-free survival and overall survival. It has been suggested that this phenomenon confers proliferative and survival advantages to the malignant blast cells. As a consequence, it is an attractive therapeutic target. As the best treatment strategy for mutated FLT3 AML remains to be defined, the addition of FLT3 inhibitor drugs to chemotherapy or to the bone marrow transplant approach has become a growing strategy. With encouraging results, this combination seems to be an attractive option. Relevant data regarding the current treatment trends on mutated FLT3 AML is reviewed here.

Heminefrectomía NOTES-híbrido transvaginal por duplicidad del sistema colector renal en el paciente adulto / Hybrid-NOTES transvaginal hemi-nephrectomy for duplicated renal collecting system in the adult patient

Introducción: La duplicación del uréter y la pelvis renal es la anomalía más común del tracto urinario superior. La heminefrectomía polar superior es el tratamiento de elección cuando la anomalía se asocia con ectopia ureteral o ureterocele en un sistema no funcionante o infección crónica del riñón. Material y método: Se describe la heminefrectomía del polo renal superior por NOTES-híbrido en una mujer de 24 años de edad con infecciones urinarias recurrentes en un sistema superior con escasa función. El procedimiento se realizó con un trócar bariátrico a través de la vagina, y un trócar multicanal (Triport, Olympus Surgical) a través del ombligo. Se utiliza bisturí ultrasónico para la heminefrectomía. El espécimen se retira por la vagina. Resultados: El tiempo operatorio fue 150 minutos y el sangrado 50 cc. Después de una semana la paciente desarrolló un urinoma en el lecho quirúrgico, que precisó exploración por vía laparoscópica. El lecho de la heminefrectomía fue fulgurado y se colocó un drenaje. La paciente se recuperó sin eventualidad tras la reintervención. Conclusiones: Se describe la técnica de heminefrectomía transvaginal con técnica NOTES híbrido. Este abordaje requiere mayor desarrollo, tanto de la instrumentación como de la técnica. La combinación de los abordajes umbilical y transvaginal restablece la triangulación y facilita la disección, pero se requiere más experiencia para determinar su seguridad, eficacia y reproducibilidad (AU)

Introduction: Duplication of the ureter and renal pelvis is the most common anomaly of the upper urinary tract. Upper pole heminephrectomy is a treatment option when duplication anomalies are associated with ureteral ectopia or ureterocele with an associated nonfunctioning or infected upper pole moiety. Material and method: We describe a NOTES hybrid transvaginal upper pole heminephrectomy in a 24 year old with recurrent infections in a poorly functioning right upper pole moiety. The procedure was performed with a bariatric trocar in the vagina, and a multichannel single-port device (Triport, Olympus Surgical) in the umbilicus. An ultrasonic scalpel was used for the heminephrectomy. The specimen was retrieved through the vagina. Results: Operative time was 150 minutes and blood loss 50 cc. One week later the patient developed urinoma at the surgical site and was re-explored laparoscopically. The cut edge of the heminephrectomy defect was fulgurated and a drain placed. The patient recovered uneventfully following re-exploration. Conclusions: We describe the technique for transvaginal Hybrid-NOTES heminephrectomy. This approach requires further development with respect to instrumentation, and surgical expertise. The combined umbilical and vaginal approached restored triangulation and facilitates dissection, but more experience is required to determine safety, efficacy and reproducibility (AU)

[Hybrid-NOTES transvaginal hemi-nephrectomy for duplicated renal collecting system in the adult patient]. / Heminefrectomía NOTES-híbrido transvaginal por duplicidad del sistema colector renal en el paciente adulto.

INTRODUCTION: Duplication of the ureter and renal pelvis is the most common anomaly of the upper urinary tract. Upper pole heminephrectomy is a treatment option when duplication anomalies are associated with ureteral ectopia or ureterocele with an associated nonfunctioning or infected upper pole moiety. MATERIAL AND METHOD: We describe a NOTES hybrid transvaginal upper pole heminephrectomy in a 24 year old with recurrent infections in a poorly functioning right upper pole moiety. The procedure was performed with a bariatric trocar in the vagina, and a multichannel single-port device (Triport, Olympus Surgical) in the umbilicus. An ultrasonic scalpel was used for the heminephrectomy. The specimen was retrieved through the vagina. RESULTS: Operative time was 150 minutes and blood loss 50 cc. One week later the patient developed urinoma at the surgical site and was re-explored laparoscopically. The cut edge of the heminephrectomy defect was fulgurated and a drain placed. The patient recovered uneventfully following re-exploration. CONCLUSIONS: We describe the technique for transvaginal Hybrid-NOTES heminephrectomy. This approach requires further development with respect to instrumentation, and surgical expertise. The combined umbilical and vaginal approached restored triangulation and facilitates dissection, but more experience is required to determine safety, efficacy and reproducibility.

[A novel technique for distal ureterectomy and bladder cuff excision]. / Nueva técnica para la ureterectomía distal y excisión de manguito vesical.

INTRODUCTION: We describe a novel endoscopic approach and provide a literature review for the "en bloc" dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum. MATERIALS AND METHODS: The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen. RESULTS: The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3. CONCLUSION: The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.

Nueva técnica para la ureterectomía distal y excisión de manguito vesical / A Novel Technique for Distal Ureterectomy and Bladder Cuff Excision

Introducción: Se describe un novedoso abordaje endoscópico y se hace una revisión de la literatura para la disección «en bloque» del uréter distal y el manguito vesical durante la nefroureterectomía radical laparoscópica, usando un puerto único multicanal transvesical con pneumovejiga (pneumovesicum). Materiales y método: El procedimiento se llevó a cabo en un hombre de 80 años de edad, con historia de hematuria macroscópica debida a carcinoma de células transicionales (CCT) en la pelvis renal izquierda, sin historia previa de CCT en vejiga. Se realizó una nefroureterectomía radical laparoscópica y el uréter fue disecado hasta la inserción en la vejiga y fue clipado. Un dispositivo de puerto único multicanal (single-port) fue insertado transvesicalmente y se estableció la pneumovejiga. Se practica una incisión de la vejiga en todo su grosor alrededor del uréter, y se va realizando una movilización intravesical del uréter distal. Subsecuentemente, se realiza un cierre hermético del defecto vesical. El uréter distal, junto con el manguito vesical, se liberan laparoscópicamente y se extraen en bloque con el espécimen. Resultados: El tiempo operatorio (nefroureterectomía radical laparoscópica, LDRP y escisión del manguito vesical por puerto único) fue de 6 horas y 15 minutos. El tiempo del manguito vesical fue de 45 minutos. No hubo complicaciones intra o postoperatorias y la sonda fue retirada al sexto día de la cirugía. El análisis histopatológico mostró CCT comprometiendo el riñón, pT3G3 pN0 (0/7). Conclusión: La técnica de abordaje del uréter distal y el manguito vesical aún no ha sido estandarizada. El manejo del manguito vesical con un puerto único multicanal es factible. Estudios adicionales son necesarios para identificar cuál es el mejor abordaje para el manejo del uréter distal durante una nefroureterectomía laparoscópica (AU)

Introduction: We describe a novel endoscopic approach and provide a literature review for the “en bloc” dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum. Materials and methods: The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen. Results: The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6 hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3. Conclusion: The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy (AU)

Varón de 69 años con masas peritoneales / No disponible

No disponible

Diagnóstico diferencial de masa pélvica / Differential diagnosis of pelvic mass

No disponible

Corangiosis placentaria como causa de mortalidad perinatal / Placental chorangiosis can be a fetalnewborn death cause

La corangiosis placentaria (hipervascularidad vellosa capilar placentaria) ocurre raramente en las gestaciones normales; es un cambio placentario a nivel del capilar velloso y se relaciona con hipoxia fetal. La corangiosis placentaria se ha asociado con diabetes gestacional, maduración vellosa retrasada, preeclampsia, infección placentaria y con importantes formas de trisomías (21, 18 y 13). También se ha asociado con nudos de cordón y abruptio placentae, de modo que la asociación de estas condiciones obstétricas aparentemente agudas con corangiosis placentaria puede ser la causa de muertes de recién nacidos (RN) que previamente fueron asumidas como resultado de una deficiente dirección del parto. Por ecografía se aprecia un aumento en el grosor placentario o hiperplacentosis que traduce el edema del órgano. Se hará el diagnóstico diferencial con el corioangioma, la corangiomatosis y con la trombosis subcorial masiva. Dado que la corangiosis es un importante signo de morbimortalidad perinatal, se enfatiza la importancia de un examen completo de la placenta en los casos en que se detecte alguna anomalía por ecografía y en todos los casos de mortalidad perinatal. Se presenta aquí un caso de corangiosis placentaria con mal resultado perinatal (muerte fetal anteparto extraclínica en la semana 36 de gestación)

The placental chorangiosis (placental villous capillary hipervascularity) happens rarely in normal gestations. It is a placental change at nevel of the villous capillary and it is related to fetal hypoxia. The placental chorangiosis has been associated with maternal diabetes, delayed villous maturation and chronic villitis, toxemia of pregnancy, placental infection and with important form to trisomies (21,18 y 13). It has also been associated with nuchal cord and placental abruption, so that the association of apparent acute obstetrical conditions with placental chorangiosis may be the cause of fetal-newborn deaths that were previously assumed to be issues of labor management. The chorangiosis is associated to an increase in the placental thickness, or hyperplacentosis, detectable by echography. The increase in the placental thickness translates the edema of the organ. The diagnosis differential of the chorangiosis will be necessary to do it with chorioangioma, chorangiomatosis and massive subcorial thrombosis. The chorangiosis would be an important sign of neonatal morbidity and mortality; by this, it has great importance the histological study of the placenta in the cases that present some anomaly and in all the cases of perinatal mortality. A case of chorangiosis with badly perinatal result appears here (extraclinical fetal death antepartum, in week 36 of gestation)

Tumor del seno endodérmico ovárico / Endodermal sinus tumor

El tumor del seno endodérmico ovárico es un tumor maligno derivado de las células germinales. Suele presentarse en mujeres jóvenes y con crecimiento muy rápido. Característicamente debuta con niveles elevados de alfafetoproteína (AFP). Su clásico mal pronóstico en la actualidad ha mejorado, y es posible obtener remisiones completas tras cirugía radical y poliquimioterapia. Presentamos el caso clínico de una paciente joven con un tumor del seno endodérmico que debutó con un cuadro de dolor abdominal agudo, debido a una torsión ovárica, inicialmente tratada con cirugía conservadora y posteriormente con poliquimioterapia y cirugía radical. En la actualidad, la paciente está viva y libre de enfermedad

The endodermal sinus ovarian tumor is a malignant tumor derived from germinal cells. Usually one appears in young women and with very fast growth. Characteristically it makes debut with elevated levels of alfafetoprotein (AFP). Its classic badly prognosis at the present time, has improved and is possible to obtain complete remissions after radical surgery an chemotherapy. This is the case of a younger patient with an endodermic sinus tumour ovarian that was presented how an acute abdominal pain because of ovarian torsion, first treated with conservative surgery and after the recurrence with multi-agent chemotherapy and radical surgery. Actually the patient is live and free of disease

Gestación en paciente con obesidad mórbida / Pregnancy in patient with morbidity obesity

La obesidad en la gestante, debe considerarse un factor de riesgo tanto para la madre como el feto, dado que se asocia a múltiples patologías (diabetes, hipertensión, trombosis) así como distocias fetales e intervenciones obstétricas. Presentamos a continuación, el caso clínico de una obesa mórbida de 185 Kg, las dificultades de control fetal y el desenlace de su embarazo

The obesity in pregnant woman must be considered of risk factor for the mother and the fetus because is associated to a lot of diseases (hypertension, diabetes, thrombosis) and high risk of fetal dystocies and obstetric surgery. This is the case of an obesity pregnant woman (185 Kg), the dificulties of fetal control and her delivery

Técnica de nefrectomía radical lumboscópica / Techniques of radical nephrectomy with 3-trocars lumboscopy

La Nefrectomia Radical sigue siendo el tratamniento de elección para Tumores Sólidos del Riñon, Actualmente existen diversas modalidades para efectuarla entre las que cuentan las técnicas endoscópicas, ya sea por Laparoscopia o por Lumboscopia. Describimos una Técnica de Nefrectomía Radical Lumboscóipica utilizando sólo 3 trocares, (diferente de la convencional con 4 trocares), interviniendo a 10 pacientes con Diagnóstico de Tumores sólidos renales. Se presentó una sola complicación intraoperatoria como fue sangramiento profuso de hilio renal que fue controlado con engrapadora endoscópica vascular. Ocho de los diez pacientes egresaron en menos de 60 horas de operados (2,5 días) y solo 2 pacientes egresaron a las 72 horas (3días) debido a inestabilidad hemodinámica que ameritó transfusión de 1-2 concentrados globulares. Los demás pacientes no presentaron complicaciones postoperatorias ni inmediatas ni tardías. Cuando esté indica Nefrectomía Radical por patología maligna, los procedimientos Endoscópicos (Laparoscipia o Lumboscopia) puede ahora considerarse como el estándar de atención en la mayoría de los casos. Los datos de eficacia intraoperatoria son comparables con los de la cirugía abierta convencional, con ventajas significativas en la morbilidad postoperatoria, convalescencia y estética. Al evadir la cavidad peritoneal, retroperitoneal proporciona ventajas adicionales que lo hacen el enfoque preferido en varios centros especializados. La técnica quirúrgica previamente detallada ha resultado un procedimiento confiable y reproducible con excelentes resultados en manos de los autores. Es importante la atención en la localización del trocar primario, la posición del balón adilatador, evitar el amontonamiento de los puertos y la familiarización con las ferencias anatómicas específicas para el abordaje retroperitoneal

Thrombin is present in the lungs of patients with primary extremity osteosarcoma and pulmonary metastases.

Osteosarcoma is a rare cancer, which metastasizes to the lung in up to 80% of cases. Thrombin is involved in metastasis and is present in the lungs of patients with pulmonary metastases (PM). To identify its role in PM and osteosarcoma, we measured thrombin levels in the bronchoalveolar lavage fluid (BALF) of 15 patients. BALF was collected at different stages of the disease and correlated with the diagnosis of PM. We also assessed fibrinogen overexpression in the tumors. We found that 11/15 (73%) patients with high thrombin levels in the lungs developed PM within the first 12 months from primary surgery. The median thrombin concentration in the BALF of these patients increased up to 8x10(-9) M (range, 3x10(-9)M-15x10(-9)M), which represents a more than 100-fold increase compared to patients without PM (p<0.0001). Eight of 15 (53%) primary and 11/15 (73%) metastatic samples showed fibrinogen overexpression. A significant difference between high thrombin levels, fibrinogen overexpression and PM was found compared to patients without PM (p=0.00073 and p=0.025). These results show that thrombin levels are increased in the lungs of patients with primary osteosarcoma and a high risk of developing PM. They suggest that thrombin may be involved in the development of PM.

Changes in the quality of rabbit semen in 14 consecutive ejaculates obtained every 15 minutes.

Modifications of semen quality related to ejaculation frequency is one of the most important and neglected factors from the standpoint of artificial insemination or sperm competition. New Zealand white rabbits (Oryctolagus cuniculus) offer an advantageous experimental model because they have characteristic sexual behavior, they present rapid ejaculation after a single intromission, they have a very short interval between successive ejaculations, and semen can be easily collected. The authors studied the modifications on sperm quality (semen volume, sperm concentration, sperm motility) produced by 14 consecutive ejaculations recovered every 15 min using stimulus females and an artificial vagina. Bucks were exposed every 15 min to a sexually receptive female. After each ejaculation the female was removed and reintroduced 15 min later. Sperm concentration showed a clear biphasic conduct. The amount of spermatozoa per milliliter decreased rapidly until ejaculate number 6, showed a highly significant increase in ejaculates 7-9, and decreased to nil in the last 2 ejaculates. Total number of ejaculated spermatozoa was 557 x 10(6), 76% of which were recovered from the first 4 ejaculates. Ejaculate volume also showed a biphasic conduct. In the first ejaculates the volume decreased linearly until ejaculate number 6, showed a significant increase in ejaculates 7-10, and then decreased. The total semen volume recovered during the experiment was 2.44 mL, 40% of which (0.98 mL) was recovered from the first 2 ejaculates. Individual motility in the first 6 ejaculates was preferentially progressive (60% of the sperms) and turned to random or in situ from the seventh ejaculate up. The proportion of spermatozoa with cytoplasmic droplets increased from ejaculates 6 and 7 up. The results seem to reflect an acceleration of semen transport through the epididymis when the demands for spermatozoa increase.

Nuestra experiencia con la laparoscopia operatoria de los anejos uterinos en dos hospitales comarcales / Our experince with operative laparoscopy for adnexal cystic masses in two general hospitals

We have reviewed our initial experience with surgi-cal laparoscopy, following it introduction in two ge-neral hospitals: Motril Hospital (Granada) and Po-niente Hospital (Almería). We describe our criteria and the diverse surgical techniques used; average operation time, average hospital stay, and intra or postoperative complications. Surgical laparoscopy is the first option for the ma-jority of adnexal cystic masses, allowing early hospi-tal discharge and minimal mortality for the patient. However, it requires a suitable period of training, with regard to its limitations, and above all to underli-ne its limited, but potencially serious complications (AU)