Radical cystectomy pentafecta: a proposal for standardisation of outcomes reporting following robot-assisted radical cystectomy.

OBJECTIVE: To propose a standardisable composite method for reporting outcomes of radical cystectomy (RC) that incorporates both perioperative morbidity and oncological adequacy. PATIENTS AND METHODS: From July 2010 to December 2017, 277 consecutive patients who underwent robot-assisted RC with intracorporeal urinary diversion (UD) for bladder cancer at our Institution were prospectively analysed. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), ≥16 lymph node (LN) yield, absence of major (grade III-IV) complications at 90 days, absence of UD-related long-term sequelae and absence of clinical recurrence at ≤12 months, were considered as having achieved the RC-pentafecta. A multivariable logistic regression model was assessed to measure predictors for achieving RC-pentafecta. RESULTS AND LIMITATIONS: Since 2010, 270 of 277 patients that had completed at least 12 months of follow-up were included. Over a mean follow-up of 22.3 months, ≥16 LN yield, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤12 months were observed in 93.0%, 98.9%, 76.7%, 81.5% and 92.2%, patients, respectively, resulting in a RC-pentafecta rate of 53.3%. Multivariable logistic regression analysis revealed age (odds ratio [OR] 0.95; P = 0.002), type of UD (OR 2.19; P = 0.01) and pN stage (OR 0.48; P = 0.03) as independent predictors for achieving RC-pentafecta. CONCLUSIONS: We present a RC-pentafecta as a standardisable composite endpoint that incorporates perioperative morbidity and oncological adequacy as a potential tool to assess quality of RC. This tool may be useful for assessing the learning curve and calculating cost-effectiveness amongst others but needs to be externally validated in future studies.

Robotic simple prostatectomy plus panniculectomy and Giant umbilical hernia repair.

INTRODUCTION: Simple prostatectomy is the gold standard for prostates >80 grams, robotic system has proven to help into speed the recovery of the patient and in morbid obesity the advantages of the robotic system can help to perform a successful surgery. CASE: 80 years old male with morbid obesity (BMI 45) and several other comorbidities, with history of an umbilical hernia and obstructive lower urinary tract symptoms in acute urinary retention. PSA was 7 ng/dl, DRE demonstrates a >100gr prostate gland. A robotic simple prostatectomy, urethropexy, umbilical hernia repair and panniculectomy in Fleur-de-Lis was performed. RESULTS: Operative time (OT) and estimated blood loss (EBL) were 438 min and 160 ml respectively. A JP drain was placed in the pelvis and 2 additional were left in the abdominal cavity with several Penrose drains. No immediate or intraoperative complications were observed. The length of stay (LOS) was 6 days without complications. Pathology report showed prostate of 304gr and benign prostatic tissue. DISCUSSION: In patients with multiple comorbidities robot-assisted surgery provides advantages of shorter LOS, EBL, less transfusion and lower rate of complications. In patients with morbid obesity where the increased girth makes difficult the open approach, robotic surgery is an ideal way to provide definitive treatment; concomitant, Fleur-de-Lis panniculectomy can correct the abdominal contour in both vertical and horizontal orientation at the same time that provides a better plane for trocar insertion, an accurate location of the needle tip and a proper position of the remote center decreasing the possible complication of port placement.

Transvesical robot-assisted simple prostatectomy with 360° circumferential reconstruction: step-by-step technique.

OBJECTIVE: To present the step-by-step technique of a 360° mucosal reconstruction after transvesical robot-assisted simple prostatectomy (RASP). PATIENT AND METHODS: We analysed the first 23 consecutive patients who underwent RASP using our 360° reconstruction between December 2015 and October 2017. After transperitoneal intravesical adenoma enucleation, a circumferential 360° reconstruction is performed. The first suture is placed at the 9 o'clock position and the edge of the urethra and bladder mucosa is approximated using 2-0 barbed suture. The reconstruction is continued counter-clockwise and the bladder mucosa is approximated to the urethra circumferentially. RESULTS: The mean (sd) operating time was 160.6 (28.1) min and the estimated blood loss was 98.6 (99.8) mL. No patients required conversion to open surgery. No intra-operative or postoperative transfusions were needed. No intra-operative complications occurred. The mean (sd) length of hospital stay was 2.1 (0.6) days. One postoperative complication was reported (respiratory distress in a patient with chronic obstructive pulmonary disease, requiring intensive care unit admission). CONCLUSION: Our 360° reconstruction during RASP is feasible and safe. The aim of the technique is to minimize use of electrocautery and decrease the raw surface area on the prostate capsule. This technical modification could potentially lessen postoperative bleeding after RASP and therefore the need for continuous bladder irrigation. In addition, it could potentially lead to mitigation of burning and irritative postoperative symptoms. Longer follow-up and comparative studies of different RASP techniques are still needed.

The Brow Fat Pad Suspension Suture: Safety Profile and Clinical Observations.

PURPOSE: To evaluate the safety, subjectively assess outcome, and emphasize surgical pearls and critical clinical observations of upper blepharoplasty performed in conjunction with the brow fat pad suspension suture procedure, previously referred to as a "browpexy variant" or "brassiere suture procedure." METHODS: A retrospective 4-year analysis of patients who underwent the brow fat pad suspension suture with upper blepharoplasty was performed. Adjunctive procedures (brow lift and ptosis repair) were categorized. The surgical technique is detailed with emphasis placed on nuances to aid in optimal outcome. RESULTS: Two hundred and sixteen patients (149 women and 47 men) underwent upper blepharoplasty with the brow fat pad suspension suture. The average patient age is 54 years and follow up is 11 months. One hundred patients had adjudicative brow lift or ptosis repair, and in 20 patients the blepharoplasty was a revision procedure. Subjective assessment of outcome showed excellent aesthetic results with improved brow projection, and enhanced lateral tarsal platform show and eyebrow/eyelid contour. Surgical complications were infrequent and patient satisfaction was high. CONCLUSIONS: This initial large series description of the brow fat pad suspension suture demonstrates that it is a safe adjunct to upper blepharoplasty, which the authors believe subjectively improves overall outcome. Evidence-based quantitative assessments of objective measures of surgical results are currently underway.

Complex Case of Skull Base Osteomyelitis Secondary to Chronic Otitis Media.

We present a case of a 58-year-old male with type II diabetes managed with metformin and insulin, who presented to the clinic with left chronic otitis media, persistent drainage, a stenotic meatus, and a prior history of 3 canal wall-down mastoidectomies and antibiotic therapy. A revision tympanoplasty with mastoidectomy was performed, and during the postoperative period, the patient had persistent pain and otorrhea, which were managed with opioids and several courses of antibiotic therapy. After symptoms persisted, imaging and culture ultimately led to the diagnosis of fungal skull base osteomyelitis, which was eventually treated successfully. While these complications are rare, their likelihood is increased with treatment delay and in the immunocompromised patient. Close management of immunocompromised patients, including diabetic patients, is vital in identifying complications early to aid in timely diagnosis and treatment to lead to the best possible outcome.

The Prominent Eye-What to Watch Out For.

Globe prominence (proptosis) may be caused by a variety of congenital or acquired conditions and poses unique challenges to aesthetic and reconstructive surgery. Once the underlying cause of proptosis is determined, a treatment plan consisting of surgical and medical procedures can be formed. Thyroid eye disease is the most common cause of proptosis and helps guide treatment options for proptosis. Although common eyelid and orbital procedures are used for proptosis correction, special care must be taken due to the unique difficulties of the distorted anatomy. Various surgical procedures and less invasive treatments can be combined to provide optimal aesthetic and functional results.

Auditory and speech performance after unilateral cochlear implantation for cochlear nerve canal stenosis.

To explore the correlation between the width of the bony cochlear nerve canal (CNC) and long-term auditory rehabilitation after unilateral cochlear implantation (CI) in pediatric patients with congenital deafness and bilateral cochlear nerve canal stenosis (CNCS). A retrospective review was performed on 10 patients with bilateral CNCS and bilateral congenital profound hearing loss who each underwent unilateral cochlear implantation. The width of the CNC was determined on computed tomography (CT) imaging and following CI, auditory and speech performance following CI were graded using categories of auditory performance (CAP), speech intelligibility rating (SIR), and the meaningful auditory integration scale (MAIS) at 24 months following implantation. No correlation was noted between CAP score and CNCS at 24 months post CI (P > .05). A positive correlation was noted between SIR score and CNC width (ρ = .81, P < .05). Similarly, a positive correlation was noted between MAIS and CNC width (ρ = .71, P < .05). The width of the CNC in patients with CNCS is positively correlated with some long-term auditory and speech outcomes after CI.

Robotic Management of Rectourethral Fistulas After Focal Treatment for Prostate Cancer.

OBJECTIVE: To describe our management strategy for rectourethral fistula (RUF) after focal treatment for prostate cancer (PCa) using 2 cases as an example. Almost 50% of RUFs are associated with energy treatment modalities for PCa. The adjacent damage to healthy tissue along with limited pliability of it makes the success of the repair troublesome. There is no standardized approach for these scenarios. MATERIALS AND METHODS: For case 1, an 83-year-old man underwent cryotherapy for PCa. On postoperative day 14, he presented with urine per rectum. Cystoscopy confirmed the presence of an RUF. Urinary and fecal diversions were unsuccessful. Three months later, robotic surgical repair was performed. For case 2, an 85-year-old man underwent salvage therapy for PCa with high-intensity focused ultrasound after previous treatment with external beam radiation therapy. Two months postoperatively, he presented with urine per rectum. A computed tomography scan confirmed the presence of an RUF. Robotic surgical repair was subsequently performed. RESULTS: Both patients underwent robotic-assisted RUF repair, including salvage prostatectomy , rectal defect closure, and omental flap placement. In the first case, healthy urethra was present after the salvage prostatectomy, and the next step was completion of a vesicourethral anastomosis. In the second case, the next step was closure of the bladder neck and suprapubic tube placement due to the extensive tissue destruction the residual urethra. Success was confirmed with imaging studies and no reported symptoms at 9 and 4 months, respectively. CONCLUSION: The robotic system is useful for the treatment of a complicated RUF. The optimal reconstruction strategy depends on the ability to reach the distal urethra, the patients' characteristics, and preferences.