Effect of Autologous Fibrin Glue on Lymphatic Drainage and Lymphocele Formation in Extended Bilateral Pelvic Lymphadenectomy in Robot-Assisted Radical Prostatectomy.

Introduction: Postoperative lymphatic drainage and lymphocele formation is a common seen complication after extended pelvic lymph node dissection (ePLND) in robot-assisted radical prostatectomy (RARP) operation. The aim of this study was to evaluate autologous fibrin glue as an additional treatment option to reduce the volume of lymphatic drainage and prevent lymphocele development. Materials and Methods: A total of 75 patients undergoing transperitoneal RARP with ePLND between January and July 2018 were enrolled in this study. Thirty-five patients who received autologous fibrin glue enrolled to study group, another 40 patients who did not receive to control group. Autologous fibrin glue was applied over the PLND areas. Age, body mass index (BMI), pathologic stages, and number of removed lymph nodes (LNs) were compared. The main endpoint was to compare postoperative lymphatic drainage volume and lymphocele formation rate between groups. Results: There was not statistically significant difference between the groups with respect to age, BMI, Gleason score, T-stage, and number of removed LNs. Autologous fibrin glue resulted in 50% (110 mL vs 210 mL; p = 0.037) and 75% reduction of postoperative drainage volume (70 mL vs 270 mL; p = < 0.0001) in study group than control group at postoperative 2nd and 3rd days, respectively. The total drainage volume was also 50% reduced in study group (277 mL vs 577 mL; p = 0.004). The incidence of asymptomatic lymphocele was 20% (n = 7) and 37.5% (n = 15) in study and control groups, respectively (p = 0.112). One patient in control group developed symptomatic lymphocele. There were no immediate or late adverse effects in study group. Conclusion: Autologous fibrin glue application reduced postoperative lymphatic drainage, and also lymphocele formation rate after extended PLND in RARP operation.

Protective effect of platelet-rich plasma on urethral injury model of male rats.

AIMS: Urethral stricture (US) formation is caused by fibrosis after excessive collagen formation following an injury or trauma to the urethra. In this study, we aimed to evaluate the effects of platelet-rich plasma (PRP) on a urethral injury (UI) model of male rats. METHODS: A UI model was used by applying a coagulation current to the urethras of male rats. There were four groups with six rats in each: control group, PRP applied to naive urethra, UI group, and UI with PRP application. PRP was applied to the urethra after a coagulation current-induced injury as soon as possible. On the 14th day, all rats were sacrificed and urethral tissues were investigated for collagen type I, collagen type III, platelet-derived growth factor-α, platelet-derived growth factor-ß, and transforming growth factor-ß using quantitative real-time polymerase chain reaction and Western blot analysis. The effect of urethral damage and healing was evaluated for collagen type I-to-collagen type III ratio. RESULTS: The collagen type I-to-collagen type III ratio was significantly higher in UI group (P < 0.05) than in the others, while UI with PRP application group had comparable results with the control group (P > 0.05). CONCLUSIONS: The results of this study show that PRP has a preventive effect on stricture formation in a UI model of rats, as shown by its effect on collagen synthesis. Further studies that eventually show the effects of PRP on human tissues are necessary and promising.

The efficacy and utilisation of preoperative multiparametric magnetic resonance imaging in robot-assisted radical prostatectomy: does it change the surgical dissection plan?

OBJECTIVE: We investigated the effect of the use of multiparametric prostate magnetic resonance imaging (mp-MRI) on the dissection plan of the neurovascular bundle and the oncological results of our patients who underwent robot-assisted radical prostatectomy. MATERIAL AND METHODS: We prospectively evaluated 60 consecutive patients, including 30 patients who had (Group 1), and 30 patients who had not (Group 2) mp-MRI before robot-assisted radical prostatectomy. Based on the findings of mp-MRI, the dissection plan was changed as intrafascial, interfascial, and extrafascial in the mp-MRI group. Two groups were compared in terms of age, prostate-specific antigen (PSA), Gleason sum scores and surgical margin positivity. RESULTS: There was no statistically significant difference between the two groups in terms of age, PSA, biopsy Gleason score, final pathological Gleason score and surgical margin positivity. mp-MRI changed the initial surgical plan in 18 of 30 patients (60%) in Group 1. In seventeen of these patients (56%) surgical plan was changed from non-nerve sparing to interfascial nerve sparing plan. In one patient dissection plan was changed to non-nerve sparing technique which had extraprostatic extension on final pathology. Surgical margin positivity was similar in Groups 1, and 2 (16% and 13%, respectively) although, Group 1 had higher number of high- risk patients. mp-MRI confirmed the primary tumour localisation in the final pathology in 27 of of 30 patients (90%). CONCLUSION: Preoperative mp-MRI effected the decision to perform a nerve-sparing technique in 56% of the patients in our study; moreover, changing the dissection plan from non-nerve-sparing technique to a nerve sparing technique did not increase the rate of surgical margin positivity.

Nerve-sparing techniques and results in robot-assisted radical prostatectomy.

Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients' risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.

Ductal Adenocarcinoma of the Prostate With a Rare Clinical Presentation; Late Gastric Metastasis.

A 67 year male had robotic prostatectomy whose pathology revealed mixed type prostate cancer composed of 55% ductal and 45% acinar components. The patient was then admitted to hospital with sudden health problems including ascites and serious vomiting attacks in the 46th month after prostatectomy and the PSA test was 4565 ng/mL. Gastroscopic biopsy was reported and proved immunhistochemically undifferentiated ductal prostate cancer metastasis. This is the first report of late gastric metastasis of ductal prostate cancer.

Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction.

INTRODUCTION: Robot-assisted bladder diverticulectomy (RABD) through a technique for easier identification of diverticulum along with concomitant management of bladder outlet obstruction (BOO) utilizing a combination of transurethral prostatectomy (TUR-P) and photoselective vaporization of prostate (PVP) is presented. MATERIALS AND METHODS: Between 2008 and 2015, 9 patients underwent RABD with concurrent treatment of BOO. Diverticula were identified by a technique of catheterizing the diverticulum and the bladder simultaneously and individually. RESULTS: Mean patient age was 62 ± 9.8 and prostate volume was 70 ± 26 ml. Mean time for endourological procedure was 77 ± 35, mean console and total operative times were 108 ± 38 and 186 ± 56 min, respectively. Mean estimated blood loss was 71 ± 37 ml. All diverticula were excised and BOO treated successfully. Bladder irrigation was not necessary in any patient. Mean hospitalization and catheter removal time was 5 ± 3 and 8 ± 3 days, respectively. No complications were observed. CONCLUSIONS: BOO is the main cause of acquired bladder diverticula and is largely due to benign prostatic hyperplasia. Concomitant performance of TUR-P and PVP along with RABD is feasible and safe. Individual catheterization of the diverticulum and bladder facilitates the identification of diverticulum even in the presence of multiple diverticula.

The use of a laparoscopic bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy: a novel technique.

PURPOSE: To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated. RESULTS: Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity. CONCLUSIONS: The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy.

Optimal control of the dorsal venous complex (DVC) is a critical step in robot-assisted radical prostatectomy (RARP). If DVC is not controlled properly, bleeding may occur during the apical dissection. On the other hand, if it is controlled well, a bloodless field is attained and, thus, a precise apical dissection and urethral division is possible. Suture ligation is the most common technique used for dorsal vein control, while some authors recommend using an endovascular stapler. Recently, athermal division and selective suture ligation technique has been reported for DVC control. We describe a new technique: Use of a bulldog clamp to control the DVC during RARP. The control of the DVC with a bulldog clamp allows a bloodless field with precise apical dissection and provides preservation of maximum urethral length while avoiding sphincteral injury.

The impact of local anesthetic volume and concentration on pain during prostate biopsy: a prospective randomized trial.

PURPOSE: To evaluate the effect of equivalent doses of local anesthetic administered at different concentrations and volumes on pain scores in patients undergoing prostate biopsy. PATIENTS AND METHODS: This study was a single-center, randomized trial. A total of 120 patients were randomized into two groups with 60 patients in each group. In group 1, 2.5 mL of 2% lidocaine (low volume-high concentration) and in group 2, 5 mL of 1% lidocaine (high volume-low concentration) was injected just lateral to the junction between the prostate base and seminal vesicle on each side under ultrasonographic guidance. Patients were given an 11 point visual analog scale (VAS) to evaluate the level of pain encountered during transrectal ultrasonographic (TRUS) probe insertion, injection of the local anesthetic, and the biopsy procedure. RESULTS: In both groups, TRUS probe insertion was the most painful stage of the procedure. With regard to local anesthetic injection, the VAS pain score was significantly lower in group 1 (1.56 vs. 2.41, P=0.001). Concerning sampling of the prostate, group 1 had a significantly lower VAS pain score compared with group 2 (1.71 vs. 2.48, P=0.008). Neither major complications nor side effects related to local anesthetic absorption occurred in both groups. CONCLUSION: Low volume-high concentration lidocaine administration provides superior analgesia compared with high volume-low concentration lidocaine during transrectal biopsy of the prostate.

Anterior and posterior reconstruction technique and its impact on early return of continence after robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: Urinary incontinence is a significant cause of morbidity after robot-assisted radical prostatectomy (RARP). Several techniques have been developed to improve continence rates. In this study, we compared the continence rates of patients who underwent RARP with total reconstruction and without reconstruction. PATIENTS AND METHODS: Between March 2005 and September 2009, 245 patients underwent RARP at our institution. The initial 120 patients (control group) underwent standard RARP without reconstruction and the last 125 patients (reconstruction group) underwent a total reconstruction technique, which included an anterior and posterior reconstruction. Patients were followed for 1, 4, 12, 24, 36, and 52 weeks after the operation. Continence was defined with strict criteria-no usage of pads and no leakage of urine. RESULTS: In the reconstruction group, the continence rates at, 1, 4, 12, 24, 36, and 52 weeks postoperatively were 71%, 72%, 80%, 84%, 86%, and 91%, respectively; in the control group, the continence rates were 23%, 49%, 76%, 80%, 85%, and 88%, respectively. CONCLUSION: The overall continence rates were similar in both groups at 52 weeks of follow-up. Patients in the total reconstruction group, however, had higher early continence rates compared with patients in the control group. The total reconstruction procedure is an efficient way to achieve an early return to continence.

Conversion to hand assistance may prevent conversion to an open procedure in standard laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: Laparoscopic surgery has received wide acceptance within the urologic community. Conversion from standard laparoscopy to the open technique may sometimes be necessary. Conversion to an open procedure may have negative implications for both the surgeon and the patient. Conversion to hand-assisted laparoscopy under these circumstances, however, may obviate open surgery. We intended to review our results and emphasize the efficacy and safety of conversion to hand assistance during standard laparoscopy when necessary. PATIENTS AND METHODS: We retrospectively reviewed the results of laparoscopic nephrectomies performed by one surgeon. Demographic and perioperative data were noted. Conversions from standard laparoscopy were analyzed in detail. RESULTS: A total of 161 laparoscopic nephrectomies were performed. Conversion was deemed appropriate in 6 of 150 standard laparoscopies. Surgery was successfully completed in five with hand assistance. The reason to convert was failure to progress in three patients and control of hemostasis in two patients. Open surgery was performed in a patient who could not tolerate pneumoperitoneum. CONCLUSION: Conversion to hand-assisted laparoscopy is safe and effective when the surgeon decides to convert from standard laparoscopy. Conversion to hand assistance may prevent conversion to an open procedure in these situations.

Robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy: comparison of outcomes.

PURPOSE: We report our initial experience with laparoscopy- and robot-assisted partial nephrectomy (RAPN) operations. MATERIALS AND METHODS: Between November 2003 and April 2009, laparoscopic partial nephrectomy (LPN) was performed in 20 patients (hand-assisted procedure in one patient) and RAPN in 11 patients. Transperitoneal approach was used in both groups. RESULTS: The patient demographics were similar in both groups. The groups were statistically comparable for body mass index (BMI), gender, and American Society of Auesthesiologists (ASA) scores. The mean tumor size was 32.1 mm (range 20-41 mm) in the RAPN group and 31.45 mm (range 15-70 mm) in the LPN group. The operative time was 226 minutes (range 120-420) in the LPN group and 185 minutes (range 120-270) in the RAPN group; the difference was not statistically significant (p = 0.07). The mean warm ischemia time was significantly shorter in the RAPN group (27.3 minutes for the RAPN group and 35.8 for the LPN group) (p = 0.02). The mean estimated blood loss was 286.4 mL in the RAPN group and 387.5 mL in the LPN group (p = 0.3). One patient (5%) had focal positive margin in the LPN group. No patient had positive surgical margins in the RAPN group. CONCLUSIONS: In this pilot study, we found that RAPN and LPN are feasible and safe operations in T1 renal tumors. The advantages for RAPN are excision of the tumor under three-dimensional vision and easy suturing with the articulated instruments of the robotic system. The cost and the need for two experienced laparoscopic surgeons are the disadvantages of robotic surgery. Larger randomized studies are needed to evaluate whether RAPN has any advantages over LPN.

Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS: Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS: The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Robot-assisted laparoscopic bladder diverticulectomy combined with photoselective vaporization of prostate: a case report and review of literature.

PURPOSE: Open surgery, endoscopic technique, and standard laparoscopic technique are surgical options for the management of bladder diverticuli. In this article, we report robot-assisted bladder diverticulectomy (RABD) and photoselective vaporization of prostate (PVP) in the same patient sequentially. To the best of our knowledge, this is the first case report of RABD combined with PVP. MATERIALS AND METHODS: A 63-year-old patient with benign prostatic hyperplasia and a secondary large bladder diverticulum underwent sequential PVP and RABD. Cystoscopic examination revealed obstructing prostate lobes and a large diverticulum at posterior wall of bladder. After completion of PVP procedure, a 16F urethral catheter was inserted into the diverticulum via outer sheath of optic urethrotome and another 16F urethral catheter was left in bladder for urinary drainage. A transperitoneal approach was preferred. The diverticulum was distended with saline infusion via the Foley catheter inside the diverticulum. The distended diverticulum was seen easily and dissected from the surrounding tissue. The bladder was closed in two separate layers. RESULTS: Total operative time, including diverticulectomy with PVP procedure, was 230 minutes, and console time was 90 minutes. The length of stay was 7 days. CONCLUSIONS: There has been always concern about the high intravesical pressures secondary to irrigant instillation that may disrupt the bladder repair. To avoid this problem we combined robotic diverticulectomy with PVP. Because of hemostatic properties of potassium-titanyl-phosphate laser, we did not encounter with bleeding after prostatectomy procedure. Moreover, we did not use irrigation, and the suture line of the bladder was kept safe. Therefore, we recommend to use greenlight laser in combined prostate and RABD operations. RABD is a feasible and safe procedure. RABD and PVP can be performed safely in the same patient sequentially.

Doppler ultrasonography-guided pelvic plexus block before systematic needle biopsy of the prostate: A prospective randomized study.

OBJECTIVES: To report a new method to block pelvic plexus and compare its efficacy with widely used periprostatic nerve block (PPNB) for transrectal ultrasonography-guided prostate biopsy. Pelvic plexuses were localized with the aid of color Doppler ultrasonography to create the pelvic block. METHODS: This study was a single-center, prospective randomized trial. A total of 80 patients were recruited in 2 groups, with 40 patients in each. In group 1 (PPNB group), 2 mL of 2% lidocaine was injected between the prostate base and seminal vesicle on each side, using ultrasonic guidance. In group 2 (pelvic plexus block group), 2 mL of 2% lidocaine was injected into the region of the pelvic plexus lateral to the tip of vesicula seminalis on each side, using ultrasonic guidance. Color Doppler ultrasonography was used to identify injection sites. Patients were given an 11-point visual analog scale (VAS) to evaluate the level of pain encountered during probe insertion, injection of local anesthetic, and biopsy procedure. RESULTS: In both groups, probe insertion was the least painful stage. With regard to local anesthetic injection, VAS pain score was significantly lower in group 2 (2.05 vs 3.12, P = .0007). Sampling the prostate was the most painful stage in both groups and group 2 had significantly lower biopsy VAS pain scores (2.7 vs 4.97, P < .0001). There were no major complications. CONCLUSIONS: Administration of lidocaine in the area of the pelvic plexus under Doppler ultrasonographic guidance provides superior analgesia to PPNB, with limited morbidity during transrectal ultrasonography-guided biopsy of the prostate.

Impact of body mass index on outcomes after robot assisted radical prostatectomy.

In this study we evaluated the impact of body mass index (BMI) on operative and perioperative parameters and surgical margin rates, in patients who underwent robotic assisted radical prostatectomy (RARP).We retrospectively reviewed 140 consecutive RARPs performed by the same surgical team. Patients were stratified based on BMI into two categories: Group I: non-obese (91 patients) and Group II: obese (49 patients). Intraoperative parameters evaluated were: total operative time, estimated blood loss (EBL), intraoperative complications, status of nerve sparing and pelvic lymph node dissection. Postoperative parameters evaluated included positive surgical margin rate, pathological Gleason score and pathological stage, final tumor volume, length of stay (LOS), and postoperative complications. The two groups were statistically comparable for age, PSA, Gleason scores and clinical stages. Mean operative time was greater in the obese group at 300.5 min versus 247.3 min in the non-obese group. Mean EBL in obese patients and non-obese patients were 396.2 and 292.8 ml, respectively. Positive surgical margin rate was 26.5% in obese and 13.1% in non-obese patients. Robotic assisted radical prostatectomy in obese patients is a feasible procedure with acceptable perioperative outcomes and complications. In our study, obesity significantly but negatively affected operative and postoperative outcomes. Moreover, obesity was associated with higher grade tumors and higher incidence of positive surgical margins. Consequently, caution is advised in performing RARP in the obese patient in the early part of a learning curve.