Purpose
Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS ...performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR).
Methods
We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications.
Results
From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP.
Conclusions
In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.
Pudendal nerve entrapment (PNE) is a common cause of resistant and disabling perineal pain. Although it is diagnosed clinically, neurophysiological tests are used for the diagnosis. Since the ...complaints worsen in the sitting position, routine pudendal somatosensory evoked potentials (SEP) performed in the supine position with midline stimulation may fail to show the PNE. We hypothesized that diagnostic value of SEP can be increased by stimulating the right and left sides separately along with provocation by maintained sitting position (dynamic SEP). Forty-nine patients with PNE and 16 healthy controls were included. SEP recordings were performed by stimulating the dorsal nerve of penis/clitoris on either side. The recordings were performed at the first supine position, at the beginning and end of a standardized sitting posture and at the second supine position. Regarding the patients with recordable responses, we might suggest that approximately 45% decrease in SEP amplitude or an amplitude value less than 1.5 mV at the termination of the sitting position (and their reversal with switching to the supine position again) are the parameters to be used with high selectivity. The dynamic pudendal SEP study described herein seems to be more valuable in PNE diagnosis than conventional SEPs.
To compare outcomes of open (O-), laparoscopic (L-) and robot-assisted laparoscopic (RAL-) radical prostatectomy (RP) performed by the same surgeon.
From May 1999 to April 2012, 484 RPs were ...performed by a single surgeon. Patients' data including age, body-mass index, serum prostate specific antigen (PSA) level, Gleason score of prostate biopsy and prostatectomy specimen, preoperative prostate and specimen volumes, clinical and pathologic stages, operation time, estimated blood loss (EBL), catheterization time, blood transfusion rate were recorded. Prospectively collected data was evaluated retrospectively by statistical analyses.
Of 484 radical prostatectomies, ORP (50), LRP (308) and RALRP (79) done by the same surgeon were included into study. Mean ages were 63.8, 62.7 and 60.3 years for ORP, LRP and RALRP respectively. Operation times for ORP, LRP and RALRP were 255, 208 and 242 minutes. EBL and hospitalization time were 602, 526, 234 mL, and 9.1, 3.2, 3.2 days for ORP, LRP and RALRP, respectively. While a significant advantage was found for EBL and complication rates in RALRP and for operation time in LRP, significant disadvantages were found in terms of catheterization time, hospitalization time, decrease in hemoglobin and blood transfusion in ORP. However, preoperative prostate volume and serum PSA level, oncologic outcomes and positive surgical margins were nearly similar in all operative techniques.
Minimally invasive techniques such as LRP and RALRP are promising techniques with comparable outcomes with ORP. Shorter catheterization time, less blood loss and fewer complication rates can be provided by RALRP.
Objective: The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) ...performed by emergency physicians (EP) as a part of this algorithm. Materials and methods: This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55 000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The χ2 test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression. Results: Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%. Conclusion: Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.
To evaluate indications for intraoperative frozen section (IFS) during robot assisted laparoscopic radical prostatectomy (RALRP) in our series.
Prospectively documented 80 patients with prostate ...cancer (PCa) who underwent RALRP were evaluated between June 2010 and July 2012. Patients were divided into 2 groups according to whether systematically IFS was performed or not. Group 1 (n=66) consisted of patients on whom systematic IFS was performed, Group 2 (n=14) consisted of patients on whom IFS was not performed. All recorded data evaluated and statistical analyses were performed for determining indications and predictive factors for IFS during RALRP. All patients were operated by single surgeon and IFS, pathological assessments were performed by experienced uro-pathologist. Statistical significant p value was p < 0.05.
Mean follow-up was 15±6 (25-4) months. Pre-operative prostate volume in trans- rectal ultrasonography (TRUS) was statistically higher in Group 1 than Group 2 (p = 0.037). The other parameters were statistically similar in both groups. According to outcomes of our study IFS was a dependent factor for positive surgical margin. Additionally, the cut off value of prostate volume in TRUS for IFS was 55.5 cc for IFS.
Preoperative measured prostate volume in TRUS may be an indicator of IFS. Therefore, more accurate information may be given to patients with prostate cancer (Pca) before RALRP by using preoperative prostate volume in TRUS.
To evaluate the effects of consistency in preoperative and postoperative Gleason scores to the operation outcomes in patients who underwent laparoscopic radical prostatectomy.
204 of 347 patients ...were included the study. 143 patients whose preoperative prostate biopsies were evaluated in the other Institute were not included into the study. The preoperative data of patients and operation outcomes were investigated from institute's files of patients. Patients were divided to three groups by using consistence of pre and postoperative Gleason scores. The tumor, node and metastasis classification were used for staging prostate cancer.
Mean age was 63 and the mean PSA level was 11 ng/dl overall. In statistical analysis PSA levels, Gleason score and rate of positive score were significantly low in Group I (p < 0.05). As in operative data, nerve sparing surgical technique was performed statistical significance higher in Group 1 than other Groups. External bleeding rate of Group II was significantly lower than the other Groups. In univariate and multivariate analysis, postoperative pathologic stage was statistical significant for consistency of pre and postoperative Gleason scores.
The modified Gleason scoring system is safe and usable for evaluating prostate biopsies and operative specimens. The consistency in pre and postoperative Gleason score effect the operation technique and also operation outcomes. Working with an experienced uro-pathologist provides to inform patients more accurate and better.
To demonstrate the operative steps of transperitoneal laparoscopic radical prostatectomy with the ascending approach (Heilbronn technique).
The technique is based on our experience with more than ...1000 cases of clinically localized prostate cancer from March 1999 to April 2004. The technical steps, instrumental requirements, patient data, complications, and reintervention rate were reviewed.
The principles of the technique include the routine use of a voice-controlled robot (AESOP) for the camera, exposure of the prostatic apex with 120 degree retracting forceps, free-hand suturing for Santorini plexus control, application of 5-mm clips during the nerve-sparing technique, control of the prostatic pedicles by 12-mm Hem-o-Lock clips, the bladder neck-sparing technique in patients with stage T1c and T2a tumors, and use of interrupted sutures for the urethrovesical anastomosis. A considerable improvement was observed when comparing the first 300 with the most recent 300 cases (mean operating time 280 v 208 minutes; conversion rate 2.7% v 0.3%; reintervention rate 3.7% v 1.0%).
Through our experience with more than 1000 cases, transperitoneal access for laparoscopic radical prostatectomy has proven to be feasible and transferable with results comparable to those of the original open approach. Besides the well-known advantages of minimally invasive surgery, the video endoscopic approach may offer further benefits in permitting optimization of the technique by video assessment.
The present experiments were undertaken to determine the levels of MDA, SOD and catalase in the testis of adolescent rats with experimental left varicoceles. Male Wistar rats, 7 weeks old and ...weighing 160–170 g, were randomly allocated into three groups. The first group of rats underwent partial ligation of the left renal vein (n=15). The second group of rats underwent a sham operation (n=7) and the third group acted as controls (n=7). Animals were sacrificed 6 weeks after surgery and dilatation of the internal spermatic veins was observed. Levels of MDA, SOD and catalase activity were measured in testis. The experimental left varicocele group showed severe testicular changes compared to other groups. The mean MDA (SEM) levels in right and left testicular tissues of varicocele bearing rats, sham‐operated rats, and control rats were 0.48 ± 0.24 and 0.31 ± 0.11, 0.22 ± 0.02 and 0.35 ± 0.12, 0.62 ± 0.29 and 0.13 ± 0.05, respectively (P > 0.05). The mean SOD (SEM) levels in right and left testicular tissues of varicocele bearing rats, sham‐operated rats, and control rats were 7790 ± 606 and 6974 ± 574, 7475 ± 1517 and 7020 ± 1106, 8727 ± 1188 and 9019 ± 1129, respectively (P > 0.05). The mean catalase (SEM) levels in right andleft testicular tissues of varicocele bearing rats,sham‐operated rats, and control rats were 75.77 ± 11.5 and 53.82 ± 10.1, 91.94 ± 14 and 94.90 ± 32, 65.40 ± 5.7 and 90.93 ± 16.4, respectively (P > 0.05). Our results suggest that oxidative status, which reflects a relative balance between reactive oxygen species (ROS) generated and ROS scavenged, may not be responsible for the testicular dysfunction associated with experimentally induced varicocele during adolescence in rats.
Behcet's syndrome is a progressive inflammatory disease which involves multiple systems. It is characterized by 3 main symptoms of iridocyclitis, and oral and genital ulcerations. Nervous system ...involvement is seen rarely in this clinical entity and is known as neurological Behcet's syndrome. Inflammation usually occurs in the brain stem, cerebellum and medulla spinalis. Voiding and erectile dysfunction can be due to progressive inflammatory reactions in the nervous and vascular systems. We prospectively evaluated the dysfunctional bladder and penis, and therapeutic options were evaluated prospectively.
A total of 24 consecutive patients diagnosed with neurological Behcet's syndrome after neurological evaluation were enrolled in this study. Neurological involvement and localization of the nervous system were proved on evaluation. Voiding and erectile dysfunction was evaluated regardless of the presence of related symptoms, and the results were compared with those of controls. Patients with voiding dysfunction on urodynamic study were treated and reevaluated symptomatically after 3 and urodynamically after 6 months.
The rate of erectile dysfunction in neurological Behcet's syndrome was 63%. Mixed type vasculogenic impotence, arterial insufficiency, veno-occlusive dysfunction and neurogenic impotence were identified in 7, 2, 2 and 1 patient, respectively. Detrusor instability was demonstrated in 12 patients with urgency incontinence, including 3 with detrusor-sphincter dyssynergia. Brain stem localization was determined in these patients on neurogenic evaluation. Significant improvement was observed with anticholinergic treatment and clean intermittent catheterization in 3 patients with detrusor-sphincter dyssynergia. Hypersensitive and hypocompliant detrusor was noted in patients with neurological Behcet's syndrome who had normal voiding habits.
Incontinence or irritable bladder symptoms should not be considered innocuous clinical findings in neurological Behcet's syndrome. Lower urinary tract function should be evaluated in all patients with this neurological syndrome. The incidence of erectile dysfunction is approximately 65% and the therapeutic approach should be determined according to lower urinary tract function.
Persistent pain after vaginal mesh surgery is a rare and agonizing entity that has devastating consequences for the patient's quality of life. Many etiologies have been blamed including nerve ...injuries and entrapments. Pudendal neuralgia is a rare chronic neuropathic pain syndrome in the anatomical territory of the pudendal nerve. Various treatment options, such as medication management, physiotherapy, nerve blocks, decompression surgery and neuromodulation, have been used, but the most appropriate treatment for pudendal neuralgia has not yet been determined. In this article, we present two cases of postoperative pelvic pain thought to be secondary to injury or mechanical distortion of the pudendal nerve after rectocele repair using mesh and tension‐free vaginal tape sling. In cases of failed conservative treatment and of mesh removal surgery, laparoscopic pudendal nerve decompression and omental flap wrapping operation can be a treatment option for pudendal neuralgia.
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