The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy II: a prospective, randomized, double blinded trial.

OBJECTIVE: To analyze postoperative ileus rates and postoperative complications between the different pneumoperitoneum settings. The secondary objective was to evaluate narcotic use and intraoperative blood loss between the different pneumoperitoneum settings. METHODS: A prospective, randomized, double blinded study was conducted at pneumoperitoneum pressures of either 12 mmHg or 15 mmHg for patients undergoing robotic assisted radical prostatectomy with bilateral pelvic lymph node dissection by a single high volume surgeon. RESULTS: The risk of ileus in the 12 mmHg group was 1.9% (2/105) compared to 3.2% (3/93) in the 15 mmHg group (OR 0.58, 95%CI 0.1-3.6). There was no difference in the risk of any complication with a complication rate of 4.8% (5/105) in the 12 mmHg arm compared to 4.3% (4/93) in the 15 mmHg arm (OR 1.1, 95% CI 0.3 - 4.3). CONCLUSION: Pneumoperitoneum pressure setting of 12 mmHg has no significant difference to 15 mmHg in the rate of postoperative complications, narcotic use, and intraoperative bleeding. Additional research is warranted to understand the optimal.

Assessing the Finances of Applying to Surgical Residency in 2019-2020: A US Nationwide Surgical Specialties Comparison.

Background The costs of applying to residency programs may affect which students choose to apply to a specialty, yet few studies have compared expenses of applying to different surgical specialties. Objective To compare individual and total expenses for applicants applying to 5 US surgical specialties during an in-person interview and recruitment period. Methods Post-match survey data from 2019-2020, from senior applicants of 123 of 141 (87.2%) US medical schools, to orthopaedic surgery (OS), neurological surgery (NS), urology (UR), plastic surgery (PS), otolaryngology (OTO) programs, was analyzed for applicant characteristics and mean application, away rotation, interview, and total expenses. Kruskal-Wallis H tests compared differences in costs between specialties. P values <.05 were significant. Results The survey data included 1136 applicants, representing a response rate of 27%, with 459 applicants to OS, 121 to NS, 191 to UR, 117 to PS, and 248 to OTO. Mean application costs were different among the specialties: OS, $1,990; NS, $1,711; UR, $1,570; PS, $1,638; and OTO, $1,612 (P≤.003). Mean interview expenses also differed: OS, $3,129; NS, $6,400; UR, $3,915; PS, $5,486; and OTO, $3,540 (P≤.001) as well as away rotation expenses: OS, $3,182; NS, $3,840; UR, $2,640; PS, $4,074; and OTO, $2,437 (P≤.029). Mean total costs were high and differed among specialties: OS, $8,205; NS, $11,882; UR, $8,207; PS, $10,845; and OTO, $7,516 (P≤.029). Conclusions Applying to surgical residencies in the pre-pandemic era was expensive, with mean costs over $10,000 for NS and PS. The largest contribution to total costs were interview expenses.

Adolescent male with bilateral succinate dehydrogenase-deficient renal cell carcinoma in a horseshoe kidney managed successfully with staged bilateral robotic-assisted partial nephrectomies: A case report.

Succinate dehydrogenase (SDH) deficient renal cell carcinoma (RCC) is a rare subset of familial RCC with only 59 cases reported. SDH deficiency is associated with hereditary paraganglioma/pheochromocytoma syndrome. Most of the cases are solitary tumors with only two reported cases of bilateral tumor. The identification of SDH deficient RCC is often the sentinel event of patient's syndromic diagnosis. We present a case of an adolescent male with bilateral tumors in a horseshoe kidney who was treated with staged robotic-assisted partial nephrectomies without complication. Both tumors were SDH negative on immunohistochemical staining.

A Hybrid Epithelial to Mesenchymal Transition in Ex Vivo Cutaneous Squamous Cell Carcinoma Tissues.

While most cases of cutaneous squamous cell carcinoma (cSCC) are benign, invasive cSCC is associated with higher mortality and is often more difficult to treat. As such, understanding the factors that influence the progression of cSCC are important. Aggressive cancers metastasize through a series of evolutionary changes, collectively called the epithelial-to-mesenchymal transition (EMT). During EMT, epithelial cells transition to a highly mobile mesenchymal cell type with metastatic capacities. While changes in expression of TGF-ß, ZEB1, SNAI1, MMPs, vimentin, and E-cadherin are hallmarks of an EMT process occurring within cancer cells, including cSCC cells, EMT within tissues is not an "all or none" process. Using patient-derived cSCC and adjacent normal tissues, we show that cells within individual cSCC tumors are undergoing a hybrid EMT process, where there is variation in expression of EMT markers by cells within a tumor mass that may be facilitating invasion. Interestingly, cells along the outer edges of a tumor mass exhibit a more mesenchymal phenotype, with reduced E-cadherin, ß-catenin, and cytokeratin expression and increased vimentin expression. Conversely, cells in the center of a tumor mass retain a higher expression of the epithelial markers E-cadherin and cytokeratin and little to no expression of vimentin, a mesenchymal marker. We also detected inverse expression changes in the miR-200 family and the EMT-associated transcription factors ZEB1 and SNAI1, suggesting that cSCC EMT dynamics are regulated in a miRNA-dependent manner. These novel findings in cSCC tumors provide evidence of phenotypic plasticity of the EMT process occurring within patient tissues, and extend the characterization of a hybrid EMT program occurring within a tumor mass. This hybrid EMT program may be promoting both survival and invasiveness of the tumors. A better understanding of this hybrid EMT process may influence therapeutic strategies in more invasive disease.

Robotic-assisted nephrectomy with level II IVC thrombectomy using Rummel Tourniquets

ABSTRACT Background: Inferior vena cava (IVC) invasion from renal cell carcinoma (RCC) occurs at a rate of 4-10% (1). IVC thrombectomy (IVC-TE) can be an open procedure because of the need for handling of the IVC (2). The first reported series of robotic management of IVC-TE started in 2011 for the management of Level I - II thrombi with subsequent case reports in recent years (2-5). Materials and Methods: The following is a patient in his 50's with no significant medical history. Magnetic resonance imaging and IR venogram were performed preoperatively. The tumor was clinical stage T3b with a 4.3cm inferior vena cava thrombus. The patient underwent robotic assisted nephrectomy and IVC-TE. Rummel tourniquets were used for the contralateral kidney and the IVC. The tourniquets were created using vessel loops, a 24 French foley catheter and hem-o-lock clips. Results: The patient tolerated the surgical procedure well with no intraoperative complications. Total surgical time was 274 min with 200 minutes of console time and 22 minutes of IVC occlusion. Total blood loss in the surgery was 850cc. The patient was discharged from the hospital on post-operative day 3 without any complications. The final pathology of the specimen was pT3b clear cell renal cell carcinoma Fuhrman grade 2. The patient followed up post-operatively at both four months and six months without disease recurrence. The patient continues annual follow-up with no recurrence. Conclusions: Surgeon experience is a key factor in radical nephrectomy with thrombectomy as patients have a reported 50-65% survival rate after IVC-TE (4).

How we do it: robotic-assisted distal ureterectomy with ureteral reimplantation

ABSTRACT Background: High risk upper tract urothelial carcinoma (UTUC) is typically managed with radical nephroureterectomy, however, renal preservation can be attempted when UTUC is localized to the distal ureter in the presence of chronic kidney disease (1-3). Distal ureterectomy is typically managed with a ureteral reimplantation and psoas hitch in order to maintain urothelial continuity, to avoid comprising the contralateral ureter, and reducing risk of chronic urinary tract infections and electrolyte abnormalities (4). We present our case of distal ureteral UTUC managed robotically with a distal ureterectomy with ureteral reimplantation. Technique and Follow-Up: Initially, an Orandi needle on a resectoscope circumscribed the left ureteral orifice. Next, robotically, the retroperitoneum was exposed and a left sided pelvic lymphadenectomy was completed. The left ureter was mobilized and the diseased ureteral segment was transected. The mobilized bladder was sutured to psoas fascia. After a cystotomy, the ureter was re-anastomosed to the bladder. The patient was discharged on postoperative day three and re-evaluated one week later with a cystogram. Final pathology was downgraded to non-invasive low-grade papillary urothelial carcinoma with negative lymph nodes and margins. Conclusion: High risk UTUC localized to the distal ureter in the setting of chronic kidney disease can be managed with a distal ureterectomy (3). Robotic distal ureterectomy with ureteral reimplantation can be assisted by an Orandi needle to achieve negative margins. Utilizing a robotic technique can offer challenges with the ureteral spatulation and reanastomosis (5-7). By fixating the ureter to the bladder prior to reanastomosis, our technique offers a solution for these difficulties.

Surgical technique for removal of tined lead for InterStim.

INTRODUCTION: We aimed to introduce our technique describing the removal of a chronic implanted tined-lead in patients with a sacral neuromodulator implant. MATERIALS AND METHODS: We performed a retrospective review of patients who had chronic sacral neuromodulator (InterStim) implanted by a single surgeon from 2001 through 2015. This simple surgical technique was developed and successfully performed to remove the leads. Primary reasons for removal were elective due to poor symptoms control and failure to maintain response or lead migration. Patient demographics, indication for implantation, as well as installation and removal complications were recorded and analyzed. RESULTS: Twenty-five patients were included [mean age: 60.4 years (32-86), 17 females]. Primary indications for sacral nerve stimulation were overactive bladder in 16 (64%), mixed incontinence in 6 (24%), urinary retention in 2 (8%), and interstitial cystitis 3 (12%). Mean implant duration was 24.2 (0.5-90) months. The existing tined lead was removed and replaced in 11 (44%) patients while the remaining 14 (56%) underwent complete removal of the unit without subsequent replacement. Successful lead removal without complications was achieved in 24 (96%) patients. CONCLUSIONS: This minimally invasive technique is a simple, safe, and effective method of removing chronic implanted tined leads en bloc.

Renal Collision and Composite Tumors: Imaging and Pathophysiology.

OBJECTIVE: To illustrate the imaging appearances of a spectrum of renal collision and composite tumors. Occurrence of collision and composite tumors in the genitourinary tract is rare compared to the usual occurrence of synchronous tumors. METHODS: Case studies were chosen that represent the different tumors. Analysis was made on both the imaging and the pathology if excision was performed. RESULTS: Presence of 2 different cell types can lead to confusing imaging findings, and biopsy or excision is typically needed for final diagnosis. Some composite tumors have a characteristic appearance on imaging based on their pathologic features. CONCLUSION: Familiarity with imaging findings may help radiologists include these tumors in their differential diagnosis.