Faster both in operative time and functional recovery by the extraperitoneal daVinci SP-based robot-assisted radical prostatectomy: a propensity score matching analysis compared to transperitoneal multiport counterpart.

We aim to investigate the peri-operative outcomes after extraperitoneal single-port based robot-assisted radical prostatectomy (eSP-RARP) utilizing the da Vinci SP system compared to conventional transperitoneal multi-port counterparts (tMP-RARP), in an era when pelvic lymph node dissection (PNLD) was omitted for the node-negative case. With exclusion criteria of volume + 50 g, suspicious rectal invasion, and node-positive disease given relatively weak grasping power and limited range of motion from the current SP system, 50 consecutive patients (Since December 2021) with localized prostate cancer underwent eSP-RARP by a single urologist maintaining identical surgical technique for 100 consecutive tMP-RARP cases (Since December 2020). Given initial selection criteria, each group was matched to a 1:1 ratio based on the risk-stratification parameters and the prostate volume. The operative time, which was maintained in each group during the study period, was significantly faster in eSP-RARP groups than in tMP-RARP (149.2 vs. 163.2 min, p = 0.025), while the weight of the removed specimen (27.1 vs. 29.0 g, p = 0.420) and margin positivity (14.7% vs. 11.7% in pT2, p = 0.812) were similar. The gas-out (1.5 vs. 1.88 days, p = 0.003) and solid diet dates (2.26 vs. 3.22 days, p < 0.001) were faster in the eSP-RARP group. The single-pad continence dates (30.5 vs. 51.9 days, p = 0.145) and zero-pad continence dates (105.5 vs. 146.2 days, p = 0.210) were identical. 90-day single-pad continence rate was 92% vs. 82% (p = 0.142, 52% vs. 56% in zero-pad continence). Based on these, daVinci SP-based RARP restored bowel function faster with shorter operative time through an extraperitoneal approach than the conventional transperitoneal multi-port counterpart while maintaining similar incontinence outcomes in cases without a routine PNLD.

Comparison of the perioperative outcomes of robot-assisted laparoscopic transperitoneal versus retraperitoneal partial nephrectomy for posterior-lateral renal tumors: a systematic review and meta-analysis.

The study aims to assess the available literature and compare the perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) for posterior-lateral renal tumors using transperitoneal (TP) and retroperitoneal (RP) approaches. Systematically searched the Embase, PubMed, and Cochrane Library databases for literature. Eligible studies were those that compared TP-RAPN and RP-RAPN for posterior-lateral renal tumors. The data from the included studies were analyzed and summarized using Review Manager 5.3, which involved comparing baseline patient and tumor characteristics, intraoperative and postoperative outcomes, and oncological outcomes. The analysis included five studies meeting the inclusion criteria, with a total of 1440 patients (814 undergoing RP-RAPN and 626 undergoing TP-RAPN). Both groups showed no significant differences in age, gender, BMI, R.E.N.A.L. score, and tumor size. Notably, compared to TP-RAPN, the RP-RAPN group demonstrated shorter operative time (OT) (MD: 17.25, P = 0.01), length of hospital stay (LOS) (MD: 0.37, P < 0.01), and lower estimated blood loss (EBL) (MD: 15.29, P < 0.01). However, no significant differences were found between the two groups in terms of warm ischemia time (WIT) (MD: -0.34, P = 0.69), overall complications (RR: 1.25, P = 0.09), major complications (the Clavien-Dindo classification ≥ 3) (RR: 0.97, P = 0.93), and positive surgical margin (PSM) (RR: 1.06, P = 0.87). The systematic review and meta-analysis suggests RP-RAPN may be more advantageous for posterior-lateral renal tumors in terms of OT, EBL, and LOS, but no significant differences were found in WIT, overall complications, major complications, and PSM. Both surgical approaches are safe, but a definitive advantage remains uncertain.

Inferior vena cava reconstruction with non-fascial autologous peritoneum: Retrospective study and literature review.

BACKGROUND: Inferior vena cava (IVC) resection is essential for complete (R0) excision of some malignancies. However, the optimal material for IVC reconstruction remains unclear. Our objective is to demonstrate the efficacy, safety, and advantages of using Non-Fascial Autologous Peritoneum (NFAP) for IVC reconstruction. To conduct a literature review of surgical strategies for tumors involving the IVC. METHODS: We reviewed all IVC reconstructions performed at our institution between 2015 and 2023. Preoperative, operative, postoperative, and follow-up data were collected and analyzed. RESULTS: A total of 33 consecutive IVC reconstructions were identified: seven direct sutures, eight venous homografts (VH), and 18 NFAP. With regard to NFAP, eight tubular (mean length, 12.5 cm) and 10 patch (mean length, 7.9 cm) IVC reconstructions were performed. Resection was R0 in 89% of the cases. Two patients had Clavien-Dindo grade I complications, 2 grade II, 2 grade III and 2 grade V complications. The only graft-related complication was a case of early partial thrombosis, which was conservatively treated. At a mean follow-up of 25.9 months, graft patency was 100%. There were seven recurrences and six deaths. Mean overall survival (OS) was 23.4 months and mean disease-free survival (DFS) was 14.4 months. According to our results, no statistically significant differences were found between NFAP and VH. CONCLUSIONS: NFAP is a safe and effective alternative for partial or complete IVC reconstruction and has many advantages over other techniques, including its lack of cost, wide and ready availability, extreme handiness, and versatility. Further comparative studies are required to determine the optimal technique for IVC reconstruction.

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience.

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

Single-Port Robotic Radical Prostatectomy Using Transvesical and Transperineal Access in Patients with a Hostile Abdomen.

Introduction: Prostate cancer diagnosis and treatment is challenging in surgically complex patients. Radical prostatectomy can be performed without peritoneal entry using novel single-port (SP) transperineal (TP) and transvesical (TV) approaches. We sought to examine the outcomes of radical prostatectomy using novel TP and TV approaches in patients with extensive prior abdominal surgeries. Materials and Methods: From 2019 to 2023, 51 patients with extensive prior abdominal surgeries were identified who underwent TP (18) and SP TV (33) robotic radical prostatectomy. Indications included history of various surgeries with open laparotomy, including J-pouch reconstruction (22, 43%), active stoma (14, 27%), and open bowel resection (9, 18%). In all patients, 12/51 (24%) had a history of incisional hernia repair with mesh. A retrospective analysis was performed. Results: All cases were completed without open conversion, bowel injuries, or blood transfusions. Length of stay was 5.6 hours for TV and 22 hours for TP. No opioids were prescribed in 91% of TV vs 56% of TP. One intraoperative complication (ureteral injury) occurred in a patient undergoing the TP approach. Postoperative complications were noted in 14/51 (27%), including 10/18 (56%) TP vs 4/33 (12%) TV. High-grade complications (Clavien 3) occurred in three patients (6%, all TP). Pathologic staging showed pT3 in 26/51 (17 TV vs 9 TP), while the remainder were pT2. Biochemical recurrences were noted in four patients (8%, three TV and one TP). Immediate continence was noted in 30% of TV patients. Long-term continence after 12 months was 92% in TV and 67% in TP. Conclusions: In patients with extensive prior abdominal surgeries, radical prostatectomy is feasible using a TP or TV approach. No bowel injuries or open conversion were observed. The SP TV approach offers advantages of shorter hospital stay, shorter catheter duration, less opioid use, fewer complications, and improved continence recovery.

Medium-Term Outcomes of the Godoy Burnia Repair: Durability of a Sutureless Laparoscopic Inguinal Hernia Repair in Girls.

Background: Several methods to repair pediatric inguinal hernias utilizing a minimally invasive technique have been developed over the decades. These methods often involve passage of suture through the peritoneum at the level of the inguinal ring. We previously described the Godoy Burnia, a laparoscopic, sutureless, cautery-only inguinal hernia repair (IHR), and this follow-up study provides longer term data for this emerging surgical technique. Methods: After institutional review board approval, a single-centered retrospective review was performed of female pediatric patients with Godoy Burnia repair from 2014 to 2021. Demographics, operative details, and outcomes were reviewed. Technique: Through a single umbilical incision, a 3 mm port and camera and 3 mm Maryland dissector are placed into the abdomen. The Maryland dissector grasps the hernia sac, everts it, and brings it into the abdomen. Electrocautery is applied to allow scarring and closure of the inguinal ring. Results: Sixty-nine hernia repairs were performed on 44 patients with ages 5 days to 16 years (average 3.9 years) and weighing 2-70 kg (average 16 kg). Average follow-up was 52.8 months, and average operative times were 14/16 minutes for unilateral/bilateral repair, respectively. Twenty-two percent of hernias were found at time of another surgery and repaired. One recurrence (1.45%) in a 16-year-old patient, and 2 patients with other short-term complications. Conclusions: Godoy Burnia, a single-incision, sutureless, laparoscopic IHR in girls, is an acceptable alternative surgical technique with a low complication and recurrence rate. The longer follow-up in this study demonstrates the durability of the repair in most age groups, and decreased operative times suggest a favorable learning curve.

Comparison of outcomes between surgical treatment of colorectal cancer metastatic to the liver and the peritoneum: Review of the literature.

BACKGROUND: Liver and peritoneum are two of the most common sites of colorectal metastases. METHODS: We searched for articles comparing outcomes of surgical management for metastatic colorectal cancer to the liver and peritoneum. CONCLUSION: Cytoreductive surgery/heated intraperitoneal chemotherapy has a similar safety profile and survival outcomes as hepatectomy for colorectal metastases after stratifying by resection status and should be incorporated earlier in the management algorithm for colorectal cancer patients with peritoneal metastases METHODS: We performed a wide search on PubMed, EMBASE, and Google Scholar for articles comparing outcomes of surgical management for metastatic colorectal cancer to the liver and peritoneum. We focused on studies comparing their perioperative clinical outcomes as well as their oncological outcomes. The following words were included in the search: comparison, outcomes, metastasectomy, colorectal cancer, liver, peritoneal surface disease, hepatectomy, and cytoreduction. RESULTS: One hundred and twenty studies were evaluated. Six of these studies met the criteria for this review.

Impact of Standard Versus Low Pneumoperitoneum Pressure on Peritoneal Environment in Laparoscopic Cholecystectomy. Randomized Clinical Trial.

BACKGROUND: High CO 2 pneumoperitoneum pressure during laparoscopy adversely affects the peritoneal environment. This study hypothesized that low pneumoperitoneum pressure may be linked to less peritoneal damage and possibly to better clinical outcomes. MATERIALS AND METHODS: One hundred patients undergoing scheduled laparoscopic cholecystectomy were randomized 1:1 to low or to standard pneumoperitoneum pressure. Peritoneal biopsies were performed at baseline time and 1 hour after peritoneum insufflation in all patients. The primary outcome was peritoneal remodeling biomarkers and apoptotic index. Secondary outcomes included biomarker differences at the studied times and some clinical variables such as length of hospital stay, and quality and safety issues related to the procedure. RESULTS: Peritoneal IL6 after 1 hour of surgery was significantly higher in the standard than in the low-pressure group (4.26±1.34 vs. 3.24±1.21; P =0.001). On the contrary, levels of connective tissue growth factor and plasminogen activator inhibitor-I were higher in the low-pressure group (0.89±0.61 vs. 0.61±0.84; P =0.025, and 0.74±0.89 vs. 0.24±1.15; P =0.028, respectively). Regarding apoptotic index, similar levels were found in both groups and were 44.0±10.9 and 42.5±17.8 in low and standard pressure groups, respectively. None of the secondary outcomes showed differences between the 2 groups. CONCLUSIONS: Peritoneal inflammation after laparoscopic cholecystectomy is higher when surgery is performed under standard pressure. Adhesion formation seems to be less in this group. The majority of patients undergoing surgery under low pressure were operated under optimal workspace conditions, regardless of the surgeon's expertise.

Pelvic Floor Peritoneum Closure Reduces Severe Postoperative Complications in Rectal Cancer Patients After Laparoscopic Anterior Rectal Resection.

BACKGROUND: Laparoscopic anterior rectal resection (LAR) is a commonly performed surgery for rectal cancer patients. Pelvic floor peritoneum closure (PC), a vital procedure in conventional anterior rectal resection, is not routinely performed in LAR. STUDY DESIGN: A total of 1118 consecutive patients with rectal cancer receiving LAR were included in this retrospective study. Patients were allocated into the PC group and the non-PC group. The occurrence of postoperative complications was compared between the 2 groups. Influential factors in anastomotic leakage (AL) were explored using univariate and multivariate logistic regression. RESULTS: There was no difference between the groups in terms of baseline characteristics. The occurrence of postoperative complications was similar between the groups. The PC group had significantly shorter postoperative hospitalization and longer operation duration compared with the non-PC group. The occurrences of Clavien-Dindo (CD) III-IV complications, CD III-IV AL, and reoperation were significantly lower in the PC group than the non-PC group. PC and a protective ileostomy were independent protective factors for CD III-IV AL. CONCLUSION: PC could reduce the occurrence of CD III-IV complications, especially CD III-IV AL, and the rate of secondary surgery, especially in patients with a lower body mass index and patients who did not receive protective ileostomies.

Peritoneal Flap for Lymphocele Prophylaxis Following Robotic-assisted Radical Prostatectomy with Lymph Node Dissection: The Randomised Controlled Phase 3 PELYCAN Trial.

BACKGROUND: Symptomatic lymphoceles (SLCs) after transperitoneal robotic-assisted radical prostatectomy with pelvic lymph node dissection (PLND) are common. Evidence from randomised controlled trials (RCTs) on the impact of peritoneal flaps (PFs) on lymphocele (LC) reduction is inconclusive. OBJECTIVE: To show that addition of PFs leads to a reduction of postoperative SLCs. DESIGN, SETTING, AND PARTICIPANTS: An investigator-initiated, prospective, parallel, double-blinded, adaptive, phase 3 RCT was conducted. Recruitment took place from September 2019 until December 2021; 6-month written survey-based follow-up was recorded. Stratification was carried out according to potential LC risk factors (extended PLND, diabetes mellitus, and anticoagulation) and surgeons; 1:1 block randomisation was used. Surgeons were informed about allocation after completion of the last surgical step. INTERVENTION: To create PFs, the ventral peritoneum was incised bilaterally and fixated to the pelvic floor. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was SLCs. Secondary endpoints included asymptomatic lymphoceles (ALCs), perioperative parameters, and postoperative complications. RESULTS AND LIMITATIONS: In total, 860 men were screened and 551 randomised. Significant reductions of SLCs (from 9.1% to 3.7%, p = 0.005) and ALCs (27.2% to 10.3%, p < 0.001) over the follow-up period of 6 mo were observed in the intention-to-treat analysis. Operating time was 11 min longer (p < 0.001) in the intervention group; no significant differences in amount (80 vs 103, p = 0.879) and severity (p = 0.182) of postoperative complications (excluding LCs) were observed. The survey-based follow-up might be a limitation. CONCLUSIONS: This is the largest RCT evaluating PF creation for LC prevention and met its primary endpoint, the reduction of SLCs. The results were consistent among all subgroup analyses including ALCs. Owing to the subsequent reduction of burden for patients and the healthcare system, establishing PFs should become the new standard of care. PATIENT SUMMARY: A new technique-creation of bilateral peritoneal flaps-was added to the standard procedure of robotic-assisted prostatectomy for lymph node removal. It was safe and decreased lymphocele development, a common postoperative complication and morbidity. Hence, it should become a standard procedure.

A novel extraperitoneal cesarean section of supravesical approach: Operative techniques.

AIM: We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique. METHODS: The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment. RESULTS: Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15-25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage. DISCUSSION: The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it. CONCLUSIONS: This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered.

Does total omentectomy prevent peritoneal seeding for advanced gastric cancer with serosal invasion?

BACKGROUND: Radical gastrectomy is composed of gastrectomy, lymph node dissection, and omentectomy. Total omentectomy (TO) is expected to reduce the incidence of peritoneal recurrence. We aimed to investigate the necessity of TO for advanced gastric cancer (AGC) with serosal invasion. METHODS: We retrospectively reviewed 310 patients who underwent radical gastrectomy with TO and 93 patients who underwent partial omentectomy (PO) for gastric cancer with serosal invasion between August, 2005 and December, 2017. Finally, 91 patients in the PO group and 91 in the TO group were enrolled based on a 1:1 propensity-score matching analysis. We evaluated surgical and oncological outcomes, including 5-year overall and recurrence-free survival rates. RESULTS: There was no statistically significant difference between the two groups in postoperative complications. Recurrence sites showed similar patterns in both groups, including peritoneal recurrence (PO vs. TO, 18.7% vs. 28.6%; p = 0.188). Five-year overall survival was better in the PO group (p = 0.018), while 5-year recurrence-free survival was similar in both groups (p = 0.066). CONCLUSION: TO might not be an essential part of preventing peritoneal recurrence for AGC with serosal invasion. PO could be considered a radical gastrectomy for T4a gastric cancer.

RAWS4all project: validation of a new silicone model for robotic TAPP inguinal hernia repair.

BACKGROUND: Trans-abdominal pre-peritoneal (TAPP) hernia repair is a complex procedure that presents several challenges. Even though, due to the high prevalence of inguinal hernia, TAPP technique is increasing in frequency and robotic Abdominal Wall Surgery (rAWS) is emerging as a valuable tool in this regard. Although inguinal TAPP procedure principles have been published and simulation is needed, the availability of validated models remains scarce. METHODS: A new low-cost model was developed to simulate inguinal rTAPP repair. For validity assessment, a new TAPP-specific fidelity questionnaire and assessment scale were developed to compare the performance of novices and experts in the simulated procedure. The models used were assessed at 60 min for execution and quality score. RESULTS: Twenty-five residents and specialists from all over the country participated in this study. Execution, quality, and global performance was higher in the seniors group compared to juniors (8.91 vs 6.36, p = 0.02; 8.09 vs 5.14, p < .001; and 17 vs. 11,5, p < .001, respectively). Overall fidelity was assessed as being very high [4.41 (3.5-5.0), α = .918] as well as face [4.31 (3.0-5.0), α = .867] and content validity [4.44 (3.2-5.0), α = .803]. Participants strongly agreed that the model is adequate to be used with the DaVinci® Robot [4.52 (3.5-5.0), α = .758]. CONCLUSION: This study shows face, content, and construct validity of the model for inguinal TAPP simulation, including for robotic surgery. Therefore, the model can be a valuable tool for learning, understanding, practicing, and mastering the TAPP technique prior to participating in the operating room.

Primary cystic echinococcosis of the peritoneum: a case report.

BACKGROUND: Peritoneal cystic echinococcosis happens usually after traumatic rupture or after surgical treatment. Primary peritoneal cystic echinococcosis is a very rare case that constitutes a diagnostic and therapeutic challenge. CASE REPORT: A 30-year-old Tunisian man was admitted for hypogastric pain since 4 months. He has a 10 cm hypogastric mass. Biological-tests were normal. A computed tomography Scan showed a cystic mass on the pelvis measuring 13 × 17 cm without echinococcosis cyst in the liver. The patient was operated and we found a cystic mass of 17 cm located on the Douglas cul-de-sac that suggest a pelvic hydatid cyst. We have performed an aspiration of the cyst confirms the diagnosis followed by injection of hypertonic solution, extarction of the germinal layer and a maximal reduction of the pericyst. The postoperative course was uneventful. CONCLUSION: Trough our case, we try to focus on the diagnosis and therapeutic options of this rare entity that we should think of in front of a patient with isolated peritoneal cyst especially in endemic country.

Analysis of the characteristics and outcomes of patients with pseudomyxoma peritonei of appendiceal origin treated with curative-intent surgery.

BACKGROUND: There are no previous studies on pseudomyxoma peritonei regarding the details of surgical procedures included in cytoreductive surgery and quantitative evaluation for peritoneal metastases by region in the abdominal cavity. This study aimed to describe the characteristics and procedural details involved in cytoreductive surgery, and survival outcomes of patients with pseudomyxoma peritonei originating from appendiceal mucinous neoplasm, and identify differences in the difficulty of cytoreductive surgery based on tumor location. METHODS: Patient characteristics and survival outcomes were studied through a retrospective review. The complete cytoreduction rate (i), the 5-year survival rate for patients with complete cytoreduction (ii), and an index as a complement (i × ii × 100) were described for patients who had tumors larger than 50 mm in one of the 13 regions of the abdominal cavity. RESULTS: A total of 989 patients were treated with curative-intent cytoreductive surgery. The median peritoneal cancer index was 18 (interquartile range, 6-29), with complete cytoreduction achieved in 702 patients (71%); the major complication rate was 17%. The median overall survival was 92.9 months, compared to 53.8 months for patients who underwent total gastrectomy and 30.4 months for those who underwent total colectomy. In the 13 abdominal regions, the index scores indicating cytoreduction difficulty were categorized into three risk groups: upper and mid-abdominal (>20), lateral abdominal (10-20), and small bowel (<10). CONCLUSIONS: Cytoreductive surgery offered favorable survival outcomes, even in cases involving total gastrectomy. The difficulty of achieving complete cytoreduction varied across abdominal regions and was classified into three levels.