Robotic Partial Nephrectomy for a Peripheral Renal Tumor

Partial nephrectomy (PN) is the preferred surgical treatment for T1 renal tumors whenever technically feasible. When properly performed, it allows preservation of nephron mass without compromising oncologic outcomes. This reduces the postoperative risk of renal insufficiency, which translates into better overall survival for the patients. PN can be technically challenging, because it requires the surgeon to complete the tasks of tumor excision, hemostasis and renorrhaphy, all within an ischemic time of preferably below 30 minutes. The surgeon needs to avoid violating the tumor margins while leaving behind the maximal parenchymal volume at the same time. Variations such as zero ischemia, early unclamping, and selective clamping have been developed in an attempt to reduce the negative impact of renal ischemia, but inevitably add to the steep learning curves for any surgeon. Being able to appreciate the fine details of each surgical step in PN is the fundamental basis to the success of this surgery. The use of the robotic assistance allows a good combination of the minimally invasive nature of laparoscopic surgery and the surgical exposure and dexterity of open surgery. It also allows the use of adjuncts such as concurrent ultrasound assessment of the renal mass and intraoperative fluorescence to aid the identification of tumor margins, all with a simple hand switch at the console. Robot-assisted laparoscopic PN is now the most commonly performed type of PN in the United States and is gaining acceptance on the global scale. In this video, we illustrate the steps of robot-assisted laparoscopic PN and highlight the technical key points for success

Bleeding After Right Laparoscopic Adrenalectomy

This report describes a case of significant postoperative hemorrhage following clipless laparoscopic adrenalectomy

Training the next generation of surgeons in robotic surgery

Context: Robotic surgery has been used with rapidly increasing frequency within urology and across many other surgical specialties. A standardized curriculum for the training and credentialing of robotic surgeons has unfortunately trailed far behind the adoption of this surgical technology. Objective: To review the current available surgical skills training models, assessments, and curricula for the purpose of training resident, fellow, and practicing surgeons in an effort to promote surgical skill proficiency and mastery and to minimize the risk of patient harm. Evidence acquisition: We performed a thorough review of available literature through a PubMed database search in February 2015. Evidence synthesis: In this article, we compiled and scrutinized the available relevant literature regarding past and present robotic surgical training techniques and credentialing criteria. This review details the basic surgical skills (both technical and nontechnical) that are necessary for individuals and teams to be successful in the operative setting. We go on to discuss the role of current robotic surgical training techniques including dry lab and virtual simulators. Finally, we offer current validated training curricula, the Global Evaluative Assessment of Robotic Skills and Fundamentals of Robotic Surgery models, which have laid the groundwork for a future standardized model that could be applied on a national and international level and across several surgical subspecialties. The ultimate goal of the review is to provide a foundation from which a future standardized training and credentialing curriculum could be based. Conclusion: There is currently a great need for a standardized curriculum to be developed and employed for the use of training and credentialing future and current robotic surgeons

Impact of positive surgical margins on overall survival after partial nephrectomy—A matched comparison based on the National Cancer Database

Introduction The impact of positive surgical margins (PSM) in partial nephrectomy (PN) has been a controversy. Previous studies on the relationship between PSM and overall survival (OS) were either underpowered or had highly dissimilar groups. We used the National Cancer Database with propensity score matching to determine the association between PSM and OS after PN. Materials and methods We identified patients with T1/T2 N0M0 renal cancer treated with PN between 2004 and 2009, and divided them into 2 groups based on their margin status. We used propensity score matching to ensure similarities in age, comorbidity score (CCI), tumor size, histology, and grade between groups. Covariates were compared by χ2 test. Cox multiple regression was used to estimate the hazard ratios (HR) for all-cause mortality. OS between matched groups were compared by log-rank, Breslow and Tarone-Ware tests. Results After excluding those with missing data on margin or survival status, 20,762 patients were eligible for matching. Each matched group had 1,265 patients, similar in age, sex, race, CCI, tumor size, histology, and grade. There were 386 recorded all-cause mortalities over a median follow-up duration of 72.6 months. Cox multiple regression showed a higher risk of all-cause mortality among cases with PSM (HR: 1.393, P = 0.001). Old age, high CCI, and large tumors had higher risks, while papillary and chromophore histologic subtypes had lower risks. PSM was associated with significantly worse OS by log-rank, Breslow, and Tarone-Ware tests. Conclusion PSM is associated with significantly worse OS after PN

Urologic surgery and COVID-19: How the pandemic is changing the way we operate

The coronavirus disease 2019 (COVID-19) pandemic has had a global impact on all aspects of healthcare, including surgical procedures. For urologists, it has affected and will continue to influence how we approach the care of patients pre-operatively, intra-operatively, and post-operatively. A risk-benefit assessment of each patient undergoing surgery should be performed during the COVID-19 pandemic based on the urgency of the surgery and the risk of viral illness and transmission. Patients with advanced age and comorbidities have a higher incidence of mortality. Routine preoperative testing and symptom screening is recommended to identify those with COVID-19. Adequate personal protective equipment (PPE) for the surgical team is essential to protect healthcare workers and ensure an adequate workforce. For COVID-19 positive or suspected patients, the use of N95 respirators is recommended if available. The anesthesia method chosen should attempt to minimize aerosolization of the virus. Negative pressure rooms are strongly preferred for intubation/extubation and other aerosolizing procedures. Although transmission has not yet been shown during laparoscopic and robotic procedures, efforts should be made to minimize the risk of aerosolization. Ultra low particulate air filters are recommended for use during minimally invasive procedures to decrease the risk of viral transmission. Thorough cleaning and sterilization should be performed post-operatively with adequate time allowed for the operating room air to be cycled after procedures. COVID-19 patients should be separated from non-infected patients at all levels of care including recovery to decrease the risk of infection. Future directions will be guided by outcomes and infection rates as social distancing guidelines are relaxed and more surgical procedures are reintroduced. Recommendations should be adapted to the local environment and will continue to evolve as more data becomes available, the shortage of testing and PPE is resolved, and a vaccine and therapeutics for COVID-19 are developed