Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer

ABSTRACT Objective: To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). Materials and Methods: Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. Results: From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. Conclusion: VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Salvage Retzius sparing robotic assisted radical prostatectomy: the first brazilian experience

ABSTRACT Introduction: Salvage Radical Prostatectomy after radiation therapy is challenging and associated with high rates of serious complications (1, 2). The novel Retzius-Sparing RARP (RS-RARP) approach has shown excellent continence outcomes (3, 4). Purpose: To describe step-by-step our Salvage Retzius-Sparing RARP (sRS-RARP) operative technique and report feasibility, safety and the preliminary oncological and continence outcomes in the post-radiation scenario. Materials and Methods: Twelve males presenting local prostate cancer recurrence after radiotherapy that underwent sRS-RARP were included. All patients performed preoperative multiparametric MRI and PSMA-PET. Surgical technique: 7cm peritoneum opening at Douglas pouch, Recto-prostatic space development, Seminal vesicles and vas deferens isolation and section, Extra-fascial dissection through peri-prostatic fat, Neurovascular bundle control, Bladder neck total preservation and opening, Anterior dissection at Santorini plexus plane, Apex dissection with urethra preservation and section, Prostate release, Vesicouretral modified Van Velthoveen anastomosis, Rocco Stitch, Oncological and continence outcomes reported with minimum 1-year follow-up. Results: Ten patients had previously received external beam radiation (EBR) whereas two received previous brachytherapy plus EBR. At 1, 3 and 12 months after surgery, 25%, 75% and 91.6% of the men used one safety pad or less, respectively. No major complications or blood transfusions were reported. Final pathology reported pT2b 41.6%, pT2c 33.3% and pT3a 25%, positive surgical margins 25%, positive lymph nodes were not found, biochemical recurrence 16.6%. Conclusion: Salvage Retzius-Sparing Robotic Assisted Radical Prostatectomy approach appears to be technically feasible and oncologically safe with potential to provide better continence outcomes.

Robotic parastomal hernia repair

ABSTRACT Introduction and Objective: Annually, more than one hundred thousand new stomas are created in the United States and near 30-50% of those will develop parastomal hernia (1). Occasionally parastomal hernias may result in life threatening complications such as bowel obstruction or strangulation requiring urgent surgical intervention (2). The minimally invasive surgery for these hernias are preferred, specially when the primary case was either laparoscopic or robot-assisted. Our objective is to demonstrate a step-by-step robotic approach with and without mesh placement and their outcomes in two different scenarios: elective and emergency. Materials and Methods: We present two cases, a 56-year-old male with three years prior robot-assisted radical cystectomy with ileal conduit and a 82-year-old male with five year post operation of laparoscopic radical cystectomy with bilateral ureterostomies. Both of them had parastomal hernia, the first case was an urgency due to bowel obstruction while the second case was an elective procedure. Using three portals, we choose the primary repair for the first case and placement of a biological mesh within the keyhole technique (3) for the second one. Results: In the first case we had an operative time of 110min, total blood loss of 40cc and for the second case an operative time of 140min with total blood loss of 20cc. Both patients were discharged within 24h and had a follow-up of 2 years with no recurrence. Conclusions: The capability for complex sutures and dissection of intracorporeal structures makes the robotic platform a powerful ally (4) and we believe in its superiority over conventional laparoscopy. Although further studies are required, our initial series suggests that the robotic parastomal hernia repair is feasible and reproducible, with or without mesh placement and could be demonstrated its use for either elective or emergency situations.

Laparoscopic and robotic urology surgery during global pandemic COVID-19

ABSTRACT Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID-19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID-19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID-19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

A safe teaching protocol of LRP (Laparoscopic Radical Prostatectomy)

ABSTRACT Purpose The LRP has a steep learning curve to obtain proficiency during which patient safety may be compromised. We present an adapted modular training system which purpose to optimize the learning curve and perform a safe surgery. Materials and Methods A retrospective analysis of the LRP safe learning protocol applied during a fellowship program over eight years (2008-2015). The surgery was divided in 12 steps and 5 levels of difficulty. A maximum time interval was stipulated in 240 minutes. After an adaptation, the fellows had 120 minutes to perform all the corresponding modules to its accumulated skill. The participants gradually and safely pass through the steps and difficulty levels. Surgeries performed by fellows were analyzed as a single group and compared to a prior series performed by tutor. Results In eight years, 250 LRP were performed (25 per apprentice) during fellowship program and 150 procedures after completion. The baseline characteristics were comparable. Most cases operated were of intermediate risk. Mean operative time was longer in the fellow group when compared to the tutor (150 min). Mean estimated blood loss were similar among the groups. Functional and oncological outcomes were better in the Tutor's group. No conversion to open surgery was performed. Conclusions The LRP safe learning protocol proved to be an effective method to optimize the learning curve and perform safe surgery. However, the tutor's functional and oncological results were better, showing that this is a procedure with a steep learning curve and proficiency demands more than 25 cases.

One wire tubeless ureteral reimplant: preliminary experience and step-by-step technique / One wire tubeless ureteral reimplantation: experiência preliminar e técnica passo-a-passo

BACKGROUND AND OBJECTIVES: Ureteral Reimplant is commonly used in pediatric and gyne-cologic surgery. Most techniques demand an experienced surgeon and lasts 2-3 hours. There is no consensus about the preferred technique until today. We report a simple modification of the Taguchi to reduce duration and make it more suitable for laparoscopic approach. METHOD: Three patients underwent distal ureteral reimplant, based on our modified Taguchi minimally invasive approach technique. Cystography and ultrasonography were performed on the 30th, 90th and 180th postoperative days to monitor kidneys; a one-year follow-up for recurrence or clinical symptoms was also performed. RESULTS: Operative time for ureteral reimplant using our technique was 15-25 minutes. The results of the performed exams on postoperative days showed normal kidneys without hydro-nephrosis. At the one-year follow-up no signs of recurrence or clinical symptoms were present. CONCLUSION: Our modifications allowed a faster and easier management of distal ureteral reimplant, with excellent perioperative and post-operative outcomes. To our knowledge this is the first detailed description of this technique through minimally invasive approach. However, further studies and a longer follow up will be necessaries to confirm the long-term outcomes and clinical benefits of our technical proposal.

JUSTIFICATIVA E OBJETIVOS: O reimplante ureteral é comumente utilizado em cirurgia pediátrica e ginecológica. A maioria das técnicas exigem um cirurgião experiente e dura 2-3 horas. Não há consenso sobre a técnica preferida até hoje. Relatamos uma modificação simples do Taguchi para reduzir sua duração e torná-lo mais adequado para a abordagem laparoscópica. MÉTODO: Três pacientes foram submetidos a reimplante ureteral distal, com base na técnica de abordagem minimamente invasiva de Taguchi modificada. Cistografia e ultra-sonografia foram realizadas no 30º, 90º e 180º dias de pós-operatório para monitorização dos rins; um acompanhamento de um ano para recorrência ou sintomas clínicos também foi realizado. RESULTADOS: O tempo operatório para o reimplante ureteral utilizando a nossa técnica foi de 15-25 minutos. Os resultados dos exames realizados nos dias pós-operatórios mostraram rins normais sem hidronefrose. No seguimento de um ano não houve sinais de recorrência ou sintomas clínicos. CONCLUSÃO: Nossas modificações permitiram um manejo mais rápido e fácil do reimplante ureteral distal, com excelentes resultados peri- e pós-operatórios. Tanto quanto sabemos, esta é a primeira descrição detalhada desta técnica através de abordagem minimamente invasiva. No entanto, estudos adicionais e um acompanhamento mais longo serão necessários para confirmar os resultados a longo prazo e os benefícios clínicos da técnica proposta.