Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje / Multiquadrant combined robotic radical prostatectomy and left partial nephrectomy: a combined procedure by a single approach

INTRODUCCIÓN: Presentar el primer caso de cirugía multicuadrante concomitante-prostatectomía radical robótica y nefrectomía parcial robótica izquierda- realizadas con técnica de puerto único utilizando el sistema quirúrgico da Vinci SP(R) (Intuitive Surgical, Sunnyvale CA, EE. UU.). PACIENTE Y METODOLOGÍA: Varón de 66 años con diagnóstico de cáncer de próstata localizado y lesión sospechosa en riñón izquierdo encontrada en tomografía axial computarizada (TAC) durante la evaluación del cáncer de próstata. Ambos procedimientos se realizaron usando una sola incisión de 3cm, y un puerto laparoscópico adicional; utilizando un Gelpoint(R) estándar (Applied Medical, Rancho Santa Margarita, CA, EE. UU.) y replicando la técnica previamente descrita de puerto único para prostatectomía radical robótica y nefrectomía parcial con el uso de la plataforma robótica puerto único prostatectomía SP(R). RESULTADOS: Tiempo operatorio total fue 256 min, con un tiempo de consola de 108min para la prostatectomía radical, y 101 min para la nefrectomía parcial, respectivamente, incluyendo un tiempo de isquemia de 26 min. La pérdida sanguínea estimada fue de 250 cc. No sé necesito transfusión. La enfermedad final de próstata fue adenocarcinoma Gleason 7 (4+3) y para la lesión renal fue carcinoma de células renales. Después de 2 meses de seguimiento, PSA fue indetectable, sin recurrencia o complicaciones. CONCLUSIONES: La técnica de puerto único presenta ventajas como: más fácil planificación quirúrgica y transición para cirugías combinadas y multicuadrantes, recuperación más rápida, dolor postoperatorio mínimo y menor uso de opioides, además de excelentes resultados cosméticos. Sugerimos que procedimientos combinados deberían ser realizados solo en instituciones con un alto volumen de pacientes, por cirujanos con amplia experiencia en cirugía robótica y con pacientes seleccionados

INTRODUCTION: To present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP(R) da Vinci surgical system (Intuitive Surgical, Sunnyvale CA, EE. UU. ). PATIENT AND METHODS: A 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint(R) (Applied Medical, Rancho Santa Margarita, CA, EE. UU. ) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP(R) robotic platform. RESULTS: Total operative time was 256 minutes (min) with a console time of 108min for radical prostatectomy, and 101 min for the partial nephrectomy respectively, including a warm ischemia time of 26 min. Estimated blood loss was 250 cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4+3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected. CONCLUSIONS: The single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients

Multiquadrant Combined Robotic Radical Prostatectomy And Left Partial Nephrectomy: A Combined procedure by A Single Approach. / Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje.

INTRODUCTION: To present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP® da Vinci surgical system (Intuitive Surgical, Sunnyvale CA, EE.UU.). PATIENT AND METHODS: A 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint® (Applied Medical, Rancho Santa Margarita, CA, EE.UU.) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP® robotic platform. RESULTS: Total operative time was 256minutes (min) with a console time of 108min for radical prostatectomy, and 101min for the partial nephrectomy respectively, including a warm ischemia time of 26min. Estimated blood loss was 250cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4+3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected. CONCLUSIONS: The single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients.

Evaluation of antifungal therapy in patients with candidaemia based on susceptibility testing results: implications for antimicrobial stewardship programmes.

BACKGROUND: Definitive antifungal therapy is typically based on Candida species and clinical status, rather than susceptibility reports. Antifungal susceptibility testing is available, but the impact on treatment decisions is unknown. The purpose of this study was to assess antifungal therapy in hospitalized patients with candidaemia during the time period between the start of empirical therapy and after antifungal susceptibility testing reports are available. METHODS: A retrospective study of 161 hospitalized patients with candidaemia was conducted. Patients who received fluconazole or an echinocandin were evaluated for changes in empirical antifungal therapy prior to and after susceptibility reporting. RESULTS: One hundred and sixty-one patients aged 59 ±â€Š16 years (male, 54%; Caucasian, 52%; APACHE II score ≥ 15, 48%; and intensive care unit, 50%) were identified, of whom 130 (81%) had fluconazole-susceptible candidaemia. Fifty-eight patients (36%) were initiated on fluconazole and 103 (64%) on an echinocandin. The mean time from culture to the susceptibility report was 5 ±â€Š2 days. Prior to availability of the susceptibility report, 20 fluconazole-initiated patients (34%) were switched to an echinocandin, while 14 echinocandin-initiated patients (14%) were switched to fluconazole. Once a susceptibility report was available, 35 of 89 (39%) patients with fluconazole-susceptible candidaemia on an echinocandin were de-escalated to fluconazole. Eleven patients on fluconazole just prior to a susceptibility report were identified with a fluconazole-resistant Candida species. CONCLUSIONS: Using antifungal susceptibility testing, patients given fluconazole with fluconazole-resistant Candida species were identified. Less than 40% of echinocandin-treated patients with fluconazole-susceptible organisms were de-escalated to fluconazole. Antifungal susceptibility testing may help to identify patients in need of clinical intervention.