V12-09 THE ANATOMIC SCALENE TRIANGLE: A USEFUL LANDMARK FOR PELVIC LYMPHADENECTOMY DURING RETZIUS-SPARING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

Objective: Pelvic lymphadenectomy (PLN) during Retzius-Sparing Robotic-Assisted Radical Prostatectomy (RS-RARP) may be challenging because the medial umbilical ligaments are not released, and the anterior structures are preserved. The incidence of symptomatic lymphoceles following PLN during RS-RARP has been reported to be higher than standard approaches (anterior technique) for RARP. We describe the anatomic scalene triangle as a useful landmark to facilitate PLN during RS-RARP and compare outcomes of PLN using this technique versus PLN for standard RARP. Patients and Surgical Procedure: This is a single center, institutional review board approved, retrospective case-control study of 200 consecutive patients undergoing RS-RARP or standard RARP. We compared perioperative factors such as age, BMI, PSA, grade group, tumor stage, lymph node yield, and incidence of symptomatic lymphoceles using t-test for continuous variables and Fisher's exact test for categorical variables. A P-value of < 0.05 was considered statistically significant. In the RS-RARP, group the anatomic scalene triangle was used as a landmark for PLN. The scalene triangle is formed superiorly by the vas deferens, medially by the medial umbilical ligament, and laterally by the external iliac vein. The peritoneum overlying the triangle is incised and an avascular plane in this space is developed. Retraction of the vas deferens and medial umbilical ligament facilitates exposure of the lymph node packet and obturator nerve. Once the lymph node packet is isolated, surgical clips are applied and mobilization of the lymph nodes is performed cranially. Once the proximal extent of the dissection has been reached, the lymph node packet is divided and removed. Results: There were no statistically significant differences between RS-RARP and standard RARP with respect to age, BMI, PSA, grade group, tumor stage, lymph node yield, or incidence of symptomatic lymphoceles. There were 4 symptomatic lymphoceles in the RS-RARP group and 1 symptomatic lymphocele in the standard RARP group. These were all treated with percutaneous drainage by interventional radiology. Conclusions: The anatomic scalene triangle is a useful landmark to facilitate a safe, reproducible, and efficient PLN during RS-RARP. We observed a 4% incidence of symptomatic lymphoceles compared to prior, smaller series which have demonstrated 8–16% incidence of symptomatic lymphoceles with PLN during RS-RARP. Although there was a higher incidence of symptomatic lymphoceles in the RS-RARP group compared to standard RARP, this was not statistically significant

Rarely Described Renal Malignancies Associated With Venous Tumor Thrombus

Collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor are uncommon renal malignancies, and their association with tumor thrombus extending into the inferior vena cava is extremely rare. Owing to the rarity of the above-mentioned malignancies and short follow-up of the cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. We herein describe in detail the first cases published of the above-mentioned renal malignancies associated with extensive inferior vena cava (IVC) thrombus, in which complex vascular reconstruction was performed. Three male patients were identified as having collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor with IVC involvement. Tumor thrombus levels were II, I and IIIc respectively. Patient ages were 42, 60 and 47 years and tumor sizes were 9.2, 10.9 and 3.7 cm correspondingly. Patient 2 underwent cavectomy, IVC replacement using polytetrafluoroethylene (Gore-Tex ) vascular graft and IVC filter deployment inside the graft. None of the patients developed any pulmonary emboli postoperatively. At the last follow-up, IVC graft for patient 2 remained patent. Owing to the rarity of the aforementioned malignancies and short follow-up of cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. Polytetrafluoroethylene (Gore-Tex) vascular grafts are an excellent and safe option for complex vascular reconstructions in patients with evidence of IVC invasion

Focal therapy for localized prostate cancer - Current status.

Focal therapy (FT) has recently gained popularity for the treatment of localized prostate cancer (PCa). FT achieves cancer control by targeting the lesions or the regions of the cancer and avoids damage to the surrounding tissues thus minimizing side effects which are common to the radical treatment, such as urinary continence and sexual function, and bowel-related side effects. Various ablative methods are used to deliver energy to the cancerous tissue. We review the different modalities of treatment and the current state of FT for PCa

Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes

A considerable number of patients require revisional surgery after laparoscopic adjustable gastric banding (LAGB). Studies that compared the outcomes of revisional sleeve gastrectomy (r-SG) and revisional Roux-en-Y gastric bypass (r-RYGB) after failed LAGB are scarce in the literature. Our objective was to determine whether significant differences exist in outcomes between r-SG and r-RYGB after failed LAGB. From 2005 to 2012, patients who underwent laparoscopic r-SG and r-RYGB after failed LAGB were retrospectively compared and analyzed. Data included demographics, indication for revision, operative time, hospital stay, conversion rate, percentage excess weight loss (%EWL), and morbidity and mortality. Out of 693 bariatric procedures, 42 r-SG and 53 r-RYGB were performed. The median preoperative weight (107.7 and 117.7 kg, respectively, p = 0.02) and body mass index (BMI) (38.5 vs. 43.2 kg/m(2), respectively, p = 0.01) were statistically significantly lower in r-SG than in r-RYGB. The mean operative time and median hospital stay were significantly shorter in r-SG than in r-RYGB (108.4 vs. 161.2 min, p &lt; 0.01) (2 vs. 3 days, p = 0.02), respectively. One patient underwent conversion to open surgery after r-RYGB (p = 0.5). The reoperation rate was lower in r-SG than in r-RYGB (0.0 vs. 3.8 %, p = 0.5). There was one postoperative leak in the r-RYGB, and the overall complication rate was significantly lower in r-SG patients than in r-RYGB patients (7.1 vs. 20.8 %, p = 0.05). The mean follow-up was significantly shorter in the r-SG group (9.8 vs. 29.3 months, p &lt; 0.01). However, the mean postoperative BMI was not different at 1 year (32.3 vs. 34.7, p = 0.29) as well as mean %EWL was (47.4 vs. 45.6 %, p = 0.77). Both r-SG and r-RYGB are safe procedures with similar outcomes in terms of %EWL. As a result of the long-term potential nutritional complication of r-RYGB, r-SG may be a better option in this group of patients. Longer follow-up is needed

Serum and urinary biomarkers for detection and active surveillance of prostate cancer

To provide a comprehensive review of the available biomarkers for the detection and active surveillance of prostate cancer and simplify decision-making while choosing between them. The limitations of PSA and mpMRI and the invasive nature of prostate biopsy has led to a constant search for serum and urinary biomarkers for both the detection and monitoring during active surveillance of prostate cancer. 4K, PHI and PCA3 have been validated in prospective clinical trials for initial detection of prostate cancer and recent evidence points to potential differentiation between indolent and aggressive cancer. However, the usage in monitoring tumor dynamics is debatable because of lack of conclusive evidence. The answer to the existing problems lies in high-quality studies to establish definitive evidence and also to help choose between the plethora of biomarkers available today. Despite the advancements in innovation and usage of biomarkers in prostate cancer, there exists tremendous potential in improving them to fulfil the unmet need that exists today. Studies to establish conclusive evidence and integration with imaging can tremendously aid diagnosis and monitoring

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula

Background: The surgical treatment of anal fistula is complex due to the possibility of fecal incontinence. Fistulotomy and cutting Setons have the same incidence of fecal incontinence depending on the complexity of the fistula. Sphincter-preserving procedures such as anal fistula plug and ligation of intersphincteric fistula tract procedure may result in more recurrence requiring repeated operations. The aim of this study was to evaluate and compare the outcomes of treating fistula in Ano utilizing two methods: Fistula plug (Gore Bio-A) and ligation of intersphincteric tract (LIFT). Methods: Fifty four patients (33 males; 21 female, median ages 42 [range 32–47] years) with high anal inter-transphenteric fistula were treated with LIFT and fistula plug procedures from September 2011 until August 2016 by a single surgeon and were retrospectively evaluated. All were followed for a median of 23.9 (range 4–54) months with clinical examination. Twenty one patients underwent fistula plug and 33 patients underwent LIFT procedure (4 patients of the LIFT group underwent LIFT and rectal mucosa advancement flap). The healing rate and complications were evaluated clinically and through telephone calls. Results: The mean operative time for the Plug was 25 ± 17 min and for the LIFT was 40 ± 20 min (p = 0.017) and the mean hospital stay was 2.4 ± 1.1 and 1.9 ± 0.3 (p = 0.01) respectively. The early complications of the plug and LIFT procedures included; anal pain (33.3%, 66.6%, p = 0.13), perianal discharge (77.8%, 91%, p = 0.62), anal pruritus (38.9%, 50.0%, p = 0.71) and bleeding per rectum (16.7%, 33.3%, p = 0.39) respectively. The overall mean follow-up was 20.9 ± 16.8 months, p = 0.68. There was no statistically significant difference between the two groups (21.9 ± 7.5 months, 19.9 ± 16.1 months, p = 0.682). The healing rate was 76.2% (16/21 patients) in the fistula plug group and 81.1% (27/33 patients) in the LIFT group (p = 0.73). Patients who had LIFT procedure and a mucosal advancement flap had 100% healing rate (4 out of 4 patients). No incontinence of stool or feces and no fistula plug expulsion were seen in our patients. The healing time ranged from 1 to 6 months after surgery. There was no post-operative perianal abscess, cellulitis or pain. Conclusions: LIFT and anal plug are safe procedures for patients with primary and recurrent anal fistula. Both techniques showed excellent results in terms of healing and complication rate. None of our patients had incontinence after 5 years follow-up. The best success rate in our patients was seen after LIFT procedure with mucosal advancement flap. Larger and controlled randomized trials are needed for better assessment of treatment options. Resumo: Introdução: O tratamento cirúrgico da fístula anal é complexo devido à possibilidade de incontinência fecal. A fistulotomia e o seton de corte têm a mesma incidência da incontinência fecal, dependendo da complexidade da fístula. Procedimentos de preservação do esfíncter, como o tampão da fístula anal e o procedimento LIFT (ligadura do trato da fístula interesfincteriana), podem resultar em mais recorrência, exigindo cirurgias repetidas. O objetivo deste estudo foi avaliar e comparar os desfechos do tratamento da fístula anal utilizando dois métodos: Tampão de fístula (Gore Bio-A) e Ligadura do Trato Interesfincteriano (LIFT). Métodos: Cinquenta e quatro pacientes (33 homens; 21 mulheres, com mediana de idade de 42 [variação 32-47] anos) foram tratados com LIFT e procedimentos com tampão de fístula de setembro de 2011 até agosto de 2016 por um único cirurgião e foram avaliados retrospectivamente. Todos foram acompanhados por uma mediana de 23,9 (variação de 4 a 54) meses com exame clínico. Vinte e um pacientes foram submetidos a tampão de fístula e 33 pacientes foram submetidos ao procedimento LIFT (4 pacientes do grupo LIFT foram submetidos a LIFT e retalho de avanço da mucosa retal). A taxa de cicatrização e as complicações foram avaliadas clinicamente e por meio de ligações telefônicas. Resultados: O tempo cirúrgico médio para o Tampão foi de 25 ± 17 minutos e para o LIFT foi de 40 ± 20 minutos (p = 0,017) e o tempo médio de internação foi de 2,4 ± 1,1 e 1,9 ± 0,3 (p = 0,01), respectivamente. As primeiras complicações dos procedimentos de tampão e LIFT incluíram: dor anal (33,3%, 66,6%, p = 0,13), secreção perianal (77,8%, 91%, p = 0,62), prurido anal (38,9%, 50,0%, p = 0,71) e sangramento pelo reto (16,7%, 33,3 %, p = 0,39) respectivamente. A média geral de acompanhamento foi de 20,9 ± 16,8 meses, p = 0,68. Não houve diferença estatisticamente significativa entre os dois grupos (21,9 ± 7,5 meses, 19,9 ± 16,1 meses, p = 0,682). A taxa de cicatrização foi de 76,2% (16/21 pacientes) no grupo com tampão de fístula e 81,1% (27/33 pacientes) no grupo LIFT (p = 0,73). Pacientes submetidos ao procedimento LIFT e um retalho de avanço da mucosa tiveram 100% de taxa de cura (4 de 4 pacientes). Nenhuma incontinência fecal e nenhuma expulsão do tampão da fístula foram observadas em nossos pacientes. O tempo de cicatrização variou de 1 a 6 meses após a cirurgia. Não houve abscesso perianal, celulite ou dor no pós-operatório. Conclusões: LIFT e tampão anal são procedimentos seguros para pacientes com fístula anal primária e recorrente. Ambas as técnicas apresentaram excelentes resultados em termos de cicatrização e taxa de complicações. Nenhum de nossos pacientes teve incontinência após 5 anos de acompanhamento. A melhor taxa de sucesso em nossos pacientes foi observada após o procedimento LIFT com retalho de avanço da mucosa. Ensaios clínicos randomizados de maior porte e controlados são necessários para melhor avaliação das opções de tratamento. Keywords: Anal fistula, Ligation of intersphincteric fistula tract, Fistula plug, Palavras-chave: Fístula anal, Ligadura do trato de fístula interesfincteriana, Tampão de fístul