Negative predictive value of PSMA PET scan for lymph node staging in patients undergoing robotic radical prostatectomy and pelvic lymph node dissection.

PURPOSE: To assess the negative predictive value of PSMA PET scan for lymph node staging in patients undergoing robotic radical prostatectomy and pelvic lymph node dissection. MATERIALS AND METHODS: A retrospective analysis of patients who underwent robotic-assisted radical prostatectomy with pelvic lymph node dissection and had a preoperative negative PSMA PET scan for metastasis was performed. The documented pre-operative variables studied included age, BMI, PSA at diagnosis, Gleason score, and biopsy ISUP grades. Patients were categorised as low, intermediate and high risk according to the D Amico classification. The post-op variables included were number of lymph nodes harvested, number of positive nodes, positivity rate, size of the node metastasis, T staging and ISUP grading. RESULTS: The overall negative predictive value of PSMA PET scan was 71.6%. Further sub-classification according to risk stratification demonstrated a NPV of 58.02%, 92.7% and 90% for high, intermediate and low risk, respectively. CONCLUSION: Pelvic lymph node dissection cannot be excluded based on a negative preop PSMA PET/CT scan.

Robotic excision of complex adrenal mass with retrocaval extension and encasement of renal hilum with renal preservation

ABSTRACT Objective: The purpose of this video is to present robotic excision of a complex adrenal mass with retrocaval extension and encasement of renal hilum in a 16 year old boy. Biochemical screening was negative for metabolically active component. Computerized tomographic scan with contrast revealed a homogenous mass of approximately 10.8 cm x 6.2 cm x 4.2 cm in the suprarenal area on right side that was extend-ing behind inferior vena cava and encasing renal hilar vessels. Imaging findings were that of a classical ganglioneuroma. Material and methods: Robot assisted laparoscopic adrenalectomy with sparing of renal hilar vasculature was performed. With patient in lateral position, five ports were used, including one for liver retraction. Da Vinci® system with four arms was docked from over the right shoulder. The displaced renal hilar structures were identified by opening Gerota's fascia. Mass was dissected completely and removed through Pfan-nensteil incision. Results: Duration of procedure was 345 minutes and console time was 290 minutes. Blood loss was 250 mL. Post-operative renal doppler showed normal blood flow. He was discharged on post-operative day three. Histopathologic examination of specimen revealed ganglioneuroma arising from adrenal gland. Conclusion: Ganglioneuroma is a rare adrenal tumor with good prognosis on surgical removal. The advent of robotic surgery has made complex surgical procedures involving vital structures like inferior vena cava be performed using minimally invasive techniques without compromising oncologic principles.

Robotic excision of complex adrenal mass with retrocaval extension and encasement of renal hilum with renal preservation.

OBJECTIVE: The purpose of this video is to present robotic excision of a complex adrenal mass with retrocaval extension and encasement of renal hilum in a 16 year old boy. Biochemical screening was negative for metabolically active component. Computerized tomographic scan with contrast revealed a homogenous mass of approximately 10.8 cm x 6.2 cm x 4.2 cm in the suprarenal area on right side that was extend-ing behind inferior vena cava and encasing renal hilar vessels. Imaging findings were that of a classical ganglioneuroma. MATERIAL AND METHODS: Robot assisted laparoscopic adrenalectomy with sparing of renal hilar vasculature was performed. With patient in lateral position, five ports were used, including one for liver retraction. Da Vinci® system with four arms was docked from over the right shoulder. The displaced renal hilar structures were identified by opening Gerota's fascia. Mass was dissected completely and removed through Pfan-nensteil incision. RESULTS: Duration of procedure was 345 minutes and console time was 290 minutes. Blood loss was 250 mL. Post-operative renal doppler showed normal blood flow. He was discharged on post-operative day three. Histopathologic examination of specimen revealed ganglioneuroma arising from adrenal gland. CONCLUSION: Ganglioneuroma is a rare adrenal tumor with good prognosis on surgical removal. The advent of robotic surgery has made complex surgical procedures involving vital structures like inferior vena cava be performed using minimally invasive techniques without compromising oncologic principles.

Robotic-assisted renal transplantation with total extraperitonealization of the graft: experience of 34 cases.

The aim of the study is to elucidate the method of complete extraperitonealization of the graft while performing transperitoneal robotic renal transplant recipient operation. This is a retrospective study of 34 robotic-assisted kidney transplant (RAKT) utilizing our technique from July 2015 to June 2017. The study is performed in a quaternary private hospital setting. The surgery was performed using our novel peritoneal flap technique allowing complete extraperitonealization of the kidney. Total of 34 patients underwent RAKT in our hospital. Mean age was 40.6 ± 8.1 years, there were 25 males and 9 females. 30 had single vessel and four had double vessels. 27 patients received living donor graft while seven had deceased donor. The mean blood loss was 88 ± 51 mL, mean anastomotic time was 32 ± 3.3 min, mean total operative time was 145 ± 15 min, mean hospital stay was 5.8 ± 2.3 days, time to nadir creatinine was 4.3 ± 1.9 days, median creatinine level at the end of 6 months was 1.3 mg/dL. There were three open conversions in our series, one of which had delayed graft function requiring hemodialytic support. Total extraperitonealization of the graft reproduces closely the technique of open kidney transplant with good graft function. This would be a step toward the ultimate goal of performing a complete extraperitoneal robotic transplant. Further refinements in robotic instruments would make this a reality in near future.

Total extraperitoneal robot assisted laparoscopic renal transplant recipient surgery.

INTRODUCTION: Renal transplant recipient surgery is conventionally performed using open technique which is total extra-peritoneal in approach whereas robot assisted renal transplant recipient surgery is performed through a transperitoneal approach. We present a case where a total extraperitoneal robot assisted renal transplant recipient surgery was performed. MATERIALS AND METHODS: A 30 year old gentleman with Ig A nephropathy and diffuse glomerulosclerosis underwent total extra-peritoneal robot assisted renal transplant recipient surgery (TERT) with sister as donor. Renal allograft was introduced through Pfannensteil incision. Alexis wound retractor was used to minimize trauma while positioning the allograft. RESULTS: There was good urine output on release of vascular clamps. Nadir creatinine was attained in three days. Patient was discharged on post-operative day six. CONCLUSION: TERT is a technically demanding procedure that closely resemble open technique while imparting the benefits of minimally invasive surgery to the patient.

Comparison between hand suture and Carter-Thomason needle closure of port sites in laparoscopy.

PURPOSE: To compare between hand closure and Carter-Thomason technique with respect to following parame­ters, time taken for port site closure, wound infection, wound dehiscence, seroma formation, port site herniation, and ascitic fluid leak. MATERIALS AND METHODS: In this study, 200 cases who underwent laparoscopic donor nephrectomy were selected and divided into two groups based on closure technique. First 100 cases underwent port closure by the standard hand closure technique and next 100 cases by Carter-Thomson needle technique. Subjects included in this group are healthy individuals with no co morbid illness. This might help to reduce the bias of complications arising from other than technical issue. RESULTS: In our study Carter-Thomason serves as a better mode of port site closure with respect to time reduced, wound and bowel related complications compared to hand closure technique. CONCLUSION: In this study closure of trocar site is better with the Carter-Thomason method when compared to hand closure technique.

Comparison of three different techniques of extraction in laparoscopic donor nephrectomy.

AIM: We compare the outcome of three different methods of graft extraction after a laparoscopic donor nephrectomy. MATERIALS AND METHODS: AFTER A CONVENTIONAL FIVE PORT LAPAROSCOPIC DONOR NEPHRECTOMY, SPECIMEN WAS EXTRACTED THROUGH ONE OF THREE APPROACHES: 1. Iliac fossa (IF) incision and hand extraction, 2. Midline (MD) periumbilical with a lower polar fat stitch incorporating gonadal vein for traction while retrieval, and 3. Pfannensteil (PF) with Gel port extraction. Estimated blood loss, operating time, warm ischemia time, incision length, pain score, analgesic consumption, hospital stay, wound complications, graft complications and recipient creatinine at 6 weeks were analyzed. RESULTS: Warm ischemia time was significantly reduced in PF group when compared to other groups. Length of the incision was less in the MD group compared to other groups. Wound complications were significantly less in PF group when compared to other groups. Graft extraction complications were significantly high in MD group compared to other two groups. CONCLUSION: Based on the results obtained, our current method of preference is by Pfannensteil incision. A controlled extraction with the use of a hand assist device would be best for donor safety and to avoid graft related complications.

Is the incidence of uretero-intestinal anastomotic stricture increased in patients undergoing radical cystectomy with previous pelvic radiation?

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To present our long-term experience comparing uretero-intestinal anastomotic (UIA) stricture rates after radical cystectomy (RC) in patients with and without previous pelvic radiotherapy (pRT), as the risk of stricture is thought to be higher in patients undergoing RC and urinary diversion (UD) with a history of pRT. PATIENTS AND METHODS: We retrospectively analysed patients who had RC and UD between 1992 and 2008 by one surgical team. Patients were divided into two groups, those with (group 1) and with no (group 2) previous pRT. Relevant clinical and pathological data were entered into a database. Patients who were symptomatic and required intervention for a UIA stricture were analysed; patients with malignant strictures were excluded. RESULTS: In all, 526 patients had RC by one surgical team during the study period; 65 had pRT before RC, 37 for prostate cancer, 23 for bladder cancer and the rest for other pelvic malignancies. All the patients in group 1 had an ileal conduit (IC) diversion. There were 250 IC and 211 neobladder diversions in group 2. There were 130 (12%) UIAs in group 1, vs 922 (88%) in group 2. There was no statistically significant difference between the groups in demographic profile and follow-up. The overall stricture rate for UIA was 1.3%; there were two (1.5%) UIA strictures in group 1 vs 12 (1.3%) in group 2. The mean (median, range) time to onset of the stricture was 10 (6, 2-39) months. There was no statistically significant difference in stricture rate between the groups (P > 0.05). CONCLUSIONS: In patients undergoing RC with UD there was no significant difference in UIA stricture rates between those with and without previous pRT.

Selective postoperative imaging after ureteroscopy.

OBJECTIVES: To evaluate the need of routine follow-up imaging after ureteroscopy. METHODS: We performed a retrospective chart review of patients undergoing ureteroscopy for urolithiasis. Selective imaging was performed in the initial postoperative phase (1-3 weeks after removal of the ureteral stent) if the procedure was classified as complicated because of the presence of an impacted stone, the need for balloon dilation, intraoperative ureteral perforation, or postoperative pain after stent removal. Uncomplicated ureteroscopy was followed by repeat imaging if the patient developed recurrent renal colic or as surveillance for new stone growth at 6-12 months of follow-up. RESULTS: A total of 267 ureteroscopic procedures were performed on 253 patients. The data from 214 of 253 patients (84.6%) who had undergone noncontrast-enhanced computed tomography imaging > or = 1 month after surgery were analyzed. The mean follow-up was 14.5 months (range 1-66). The incidence of stricture was 1.4% (3/214). The incidence in the selective imaging (complicated ureteroscopy) group was 5.3% (3/56). In uncomplicated ureteroscopy group, it was 0% (0/158). Ureteral stricture developed in 3 of 11 patients with stone impaction (27.2%, P = .002), 2 of 14 patients undergoing ureteral balloon dilation (10.4%, P = .0052), and in 1 of 6 patients with an intraoperative mucosal perforation (16.6%, P = .0326). Persistent postoperative pain after stent removal was not predictive of stricture formation (3.6%, P = .139). CONCLUSIONS: The results of our study have shown that selective imaging as determined by the intraoperative findings of complicated ureteroscopy (eg, impacted stone, balloon dilation, mucosal perforation) will detect postoperative ureteral strictures. Routine follow-up imaging is not essential after uncomplicated ureteroscopy.