Crossover transseptal vasovasostomy: alternative for very selected cases of iatrogenic injury to vas deferens

ABSTRACT Inguinal herniorraphy is a possible cause of iatrogenic seminal tract obstruction. Diagnosing and correcting these vasal injuries can be challenging. Successful re-anastomosis is technically challenging, with relatively low success rates. An uncommon alternative for selected cases is the crossover transseptal vasovasostomy. We herein report a case of a 36-year-old male patient with vas deferens injury after herniorraphy and a contralateral hypotrophic testis. He was successfully treated through microsurgical crossover transseptal vasovasostomy, with spontaneous pregnancy achieved, and the technique is presented in details.

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.

A Safe teaching protocol of LRP (laparoscopic radical prostatectomy).

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.

Nutcracker Syndrome: laparoscopic external stenting of the renal vein (″the shield technique″).

Nutcracker syndrome refers to the complex of clinical symptoms caused by the compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery, leading to stenosis of the aortomesenteric portion of the LRV and dilatation of the distal portion. Hematuria, proteinuria, flank pain, varicocele and pelvic congestion may occur, occurring more frequently in young adults. Conservative management, might be the option whenever it is possible. When surgical treatment is required, classically open surgery have been performed, with major surgeries as LRV transposition or bypass techniques. The main caveats regards the fact that these are large and risky surgeries. Endovascular surgery with venous stent placement has gained some space as it is minimally invasive alternative. However, venous stents are associated with a high number of trombotic complications and in many cases requirement of life-long anticoagulants. External stenting of the LRV with this "shield technique" is a minimally invasive alternative, with good medium term results. We herein demonstrate our second experience with the technique of this surgery in a patient with 12 months of follow up and excellent results.