Relação entre grau de preservação do feixe neurovascular e desfechos funcionais e oncológico trifecta em prostatectomias radicais assistidas por robô

Objetivo: Avaliar o grau de preservação do feixe neurovascular durante a prostatectomia radical assistida por robô e comparar ao desfecho combinado trifecta (controle oncológico, continência e função sexual) doze meses após a cirurgia. Materiais e Métodos: Coorte retrospectiva de pacientes que foram submetidos à prostatectomia radical assistida por robô tiveram a preservação do feixe neurovascular graduada de 0 a 8 conforme a classificação visual subjetiva da Hopkins. Eles foram divididos em dois grupos, conforme a mediana do grau: escores maior ou igual a seis e escores menores que seis. O desfecho principal foi o resultado combinado trifecta, coletados prospectivamente, e os desfechos secundários foram a avaliação individualizada dos critérios do trifecta (taxa de ereção, de continência e de PSA indetectável). Uma análise secundária foi realizada com os grupos subdivididos conforme o SHIM pré-operatório Resultados: 100 prostatectomias radicais assistida por robô foram realizadas, das quais 83 foram incluídas. Tiveram 53 pacientes com grau maior ou igual a seis (grupo 1) e 30 pacientes com grau menor que seis (grupo 2). 66,6% dos pacientes (35/53) no grupo 1 tiveram o desfecho combinado trifecta comparado com 33,3% (10/30) no grupo 2 (p = 0,017). Individualmente, a função erétil foi superior no grupo 1 (73,6%) comparado ao grupo 2 (46,7%) (p = 0,014). Ambos resultados se mantiveram no grupo com SHIM pré-operatório ≥17. Conclusão: O grau de preservação do feixe neurovascular na prostatectomia radical está associado com um melhor desfecho combinado trifecta um ano após a cirurgia.Objective: To evaluate the neurovascular bundle preservation grades during robotic-assisted radical prostatectomy and compared to the trifecta combined outcome (oncologic control, continence, and sexual function) twelve months after the surgery. Material and Methods: Cohort of patients who underwent nerve-sparing robotic-assisted radical prostatectomy had the neurovascular bundle preservation retrospectively graded from 0 to 8 according to the Hopkins subjective visual classification. Patients then were divided into two groups, according to the median of nerve-sparing grading: those with score six or high and those with score less than six. Main outcome was the trifecta combined outcome and secondary outcomes was the individual trifecta criteria (prospective analysis). A secondary analysis with groups divided according to pre-operatory SHIM score was made. Results: One hundred robotic-assisted nerve-sparing radical prostatectomy were performed, of which 83 were included. There were 53 patients with grading greater than or equal to six (group 1) and 30 patients less than six (group 2). 66.6% patients (35/53) in group 1 had a trifecta combined outcome of compared to 33.3% (10/30) in group 2 (p = 0.017). Individually, the erectile function was higher in group 1 (73.6%) compared to group 2 (46.7%) (p = 0.014). Both the results of the combined endpoint trifecta and erection were also maintained in the group with preoperative SHIM ≥17. Conclusions: The grading of preservation of the neurovascular bundle in radical prostatectomy is related to a better combined trifecta outcome one year after surgery

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

ABSTRACT Purpose: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. Material and Methods: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. Results: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. Conclusion: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve

Easy, reproducible extraperitoneal pelvic access for robot - assisted radical prostatectomy

ABSTRACT Robot - assisted radical prostatectomy is commonly performed transperitoneally (tRARP), although the extraperitoneal (eRARP) approach is a safe and effective alternative that may be preferred in certain situations. We developed a novel method of direct access into the space of Retzius with a visual obturator port (Visiport™) for laparoscopic or robotic prostatectomy. We present an instructional video of extraperitoneal pelvic access for eRARP with both internal and external camera views. The patient is first placed in lithotomy and 15° Trendelenburg position. The camera is inserted infraumbilically and angled caudally. The pre-peritoneal space is accessed through the anterior rectus fascia using a Visiport™ (Covidien, $60 www.esutures.com), and the working space is developed with a kidney - shaped balloon OMSPDBS2™ (Covidien,$ 49 www.esutures.com). After the space is insufflated, subsequent trocars are angled in extraperitoneally under direct vision. The average time from incision to final port placement after a learning curve of about 50 cases is 8 minutes (IQR 7-10). We have performed over 1.000 cases using this technique and eRARP has become our procedure of choice. Our last 500 + cases were performed robotically. Approximately 10% of the time peritoneotomies were noted, but rarely did these require conversion to tRARP. There have been no bowel or other abdominal organ injuries, major vascular or other complications in any of these cases