Surgical Education and Learning Theory

Surgical education has evolved over the last three decades due to changes in surgery starting with the adoption of minimally invasive and image-guided surgical techniques. It has therefore driven change in the traditional approach to the teaching and in the acquisition of new surgical skills, both technical and non-technical. Always considering the educational theory principles, the simulation will undoubtedly play a crucial role and will become a basic step for assessing certain skill competencies before progression to real-life scenarios. It will enhance the development of skills, knowledge, and attitudes generating a new generation of successful medical trainers and learners

¿Existe asociación entre las escalas RENAL y PADUA y el cumplimiento de Trifecta y Pentafecta?

Introduction: RENAL and PADUA scoring systems have been designed and validated as a method to assess the complexity of renal masses and predict the risk of perioperative complications. We aimed to evaluate the association between RENAL and PADUA nephrometry scores with the Trifecta and Pentafecta’s achievement.Materials and methods: We retrospectively analyzed the data from 102 patients with renal cell carcinoma who underwent partial nephrectomy from January 2011 to October 2018 at our institution. Radiological characteristics of the renal masses were scored according to the RENAL and PADUA classification. Trifecta and Pentafecta’s achievement was analyzed. We performed a descrip-tive analysis and used de χ2 test to evaluate the relationship between PADUA and RENAL scores and Trifecta and Pentafecta’s achievement.Results: Among 102 patients, the median tumor size was 2.7 cm (IQR 0.8-7.5), the median RENAL score was 7 (IQR 4-11) and PADUA score 8 (IQR 6-14). The overall rate of postoperative complications was 21.6% (n=22). The rates of Trifecta and Pentafecta achievement were 50% (n=51/102) and 46.1% (n=47/102), respectively. Trifecta and Pentafecta’s achievement was higher when the PADUA score was ≤10 (OR 3.62; IC95% (1.08-12.11); p=0.0317) and (OR 4.98; IC95% (1.32-18.7); p=0.0175), respective-ly. Likewise, Trifecta and Pentafecta’s achievement was higher in patients with RENAL score ≤ 8 (OR 4.09; IC95% (1.46-11.42); p=0.0072) and (OR 4.92; IC95% (1.66-14.51); p=0.0039), respectively.Conclusions: The anatomic complexity of the renal masses measured by the RENAL and PADUA nephrometry scores could be related with worse oncological and functional outcomes following partial nephrectomy.Introducción: Las escalas RENAL y PADUA fueron diseñadas como método para determinar la complejidad de las masas renales y predecir el riesgo de complicaciones perioperatorias de los tumores renales. El objetivo de nuestro estudio fue investigar la existencia de asociación entre dichas escalas y el cumplimiento de Trifecta y Pentafecta.Material y métodos: Analizamos retrospectivamente 102 pacientes con tumores renales tratados mediante nefrectomía parcial entre 2011 y 2018. Se calcularon las escalas RENAL y PADUA para cada caso según las imágenes obtenidas por TC o RM y se analizó el cumplimiento de Trifecta y Pentafecta. La asociación entre las variables se estimó con la prueba chi cuadrado.Resultados: La mediana de tamaño tumoral fue de 2.7 cm (RIQ 0.8-7.5), la mediana de puntuación en la escala RENAL de 7 (RIQ 4-11) y la mediana en la escala PADUA de 8 (RIQ 6-14). El cumplimiento de Trifecta y Pentafecta fue del 50% (n=51/102) y 46.1% (n=47/102), respectivamente. El cumplimiento de Trifecta y Pentafecta fue mayor cuando la puntuación en la escala PADUA era ≤10 (OR 3.62; IC95% (1.08-12.11); p=0.0317) y (OR 4.98; IC95% (1.32- 18.7); p=0.0175), respectivamente. De manera similar, el cumplimiento de Trifecta y Pentafecta fue mayor en los pacientes con la puntuación en la escala RENAL ≤ 8 (OR 4.09; IC95% (1.46-11.42) y (OR 4.92; IC95% (1.66-14.51); p=0.0039), respectivamente.Conclusiones: La complejidad anatómica de las masas renales medida mediante las escalas PADUA y RENAL podría estar rela-cionada con peores resultados oncológicos y funcionales de los pacientes sometidos a nefrectomías parciales

Manejo endovascular de la estenosis de la arteria renal en el trasplante renal

INTRODUCTION: Transplant renal artery stenosis is a recognized complication of kidney transplantation associated with allograft dysfunction and even graft loss. It is a commonly missed but potentially treatable complication that may present from months to years after transplant surgery.  Its prompt diagnosis and adequate therapeutic management are essential to avoid renal function loss. MATERIAL AND METHODS: We retrospectively analysed the data from two 72-year-old patients transplanted in 2017 at our institution. Both with arterial hypertension, chronic ischemic heart disease and end-stage renal disease due to nephroangiosclerosis and membranous glomerulonephritis, respectively; presented allograft dysfunction in the immediate postoperative period. With this finding and the evidence of peak systolic velocity of >200 cm/s in the transplant renal artery we suspected transplant renal artery stenosis, confirmed by angiography and CT scan. An endovascular management with stent placement was performed. RESULTS: Both patients were managed by percutaneous transluminal renal angioplasty and stent placement with good morphological outcomes. After the procedure both patients presented a progressive renal function improvement, being discharged after 8 and 11 days, respectively. Since then, both patients have remained with stable renal function, presenting a glomerular filtration rate of 67 mL/min/1.73m2 and 60 mL/min/1.73m2 12 months after the surgery. No complications have been noticed after 14 months. CONCLUSION: Percutaneous transluminal renal angioplasty and stent placement is an effective and safe technique. Nevertheless, high experience is mandatory to reduce the number of complications and optimize the results of this technique.   Key words: kidney transplant, arterial stenosis, minimally invasive, endovascular surgery.INTRODUCCIÓN: La estenosis de la arteria renal es la complicación vascular más frecuente del trasplante renal y una de las principales causas de pérdida del injerto y muerte prematura en los pacientes trasplantados. A pesar de ser potencialmente tratable, es frecuentemente infradiagnosticada, por lo que su diagnóstico precoz y manejo terapéutico adecuado resulta fundamental para evitar la pérdida de función renal.   MATERIAL Y MÉTODOS: Analizamos retrospectivamente el caso de dos pacientes de 72 años trasplantados en nuestro centro en 2017. Ambos pacientes, con antecedentes de hipertensión arterial, cardiopatía isquémica crónica y enfermedad renal crónica terminal secundaria a nefroangioesclerosis y glomerulonefritis membranosa, respectivamente; presentaron un empeoramiento de la creatinina en el postoperatorio inmediato del trasplante renal. Ante este hallazgo y la evidencia de velocidades pico sistólicas >200 cm/s en la ecografía-doppler se sospechó una estenosis de la arteria del injerto, posteriormente confirmada con angiografía y angio-TC, respectivamente. Por lo que se realizó una revascularización percutánea e implante de stent.   RESULTADOS: Se realizó la angioplastia con balón y colocación de stent, bajo anestesia local, obteniendo un buen resultado morfológico, sin complicaciones inmediatas. Tras el procedimiento ambos pacientes presentaron una mejoría progresiva de la función renal manteniendo un buen ritmo de diuresis, siendo dados de alta a los 8 y 11 días del mismo. Desde entonces, la función renal de ambos pacientes se ha mantenido estable presentando a los 12 meses un filtrado glomerular alrededor de 67 mL/min/1.73m2 y 60 mL/min/1.73m2, respectivamente.  Sin evidencia de complicaciones tras 14 meses del procedimiento.   CONCLUSIONES: La angioplastia con balón y colocación de stent en la estenosis de la arteria renal en el trasplante es una técnica segura y efectiva. Sin embargo, es necesaria una elevada experiencia para disminuir el número de complicaciones y optimizar los resultados de esta técnica.   Palabras clave: trasplante renal, estenosis arterial, manejo mínimamente invasivo, cirugía endovascular

Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective: In the last years, robotic surgery was introduced in several different settings with good perioperative results. However, its role in the management of adrenal masses is still debated. In order to provide a contribution to this field, we described our step-by-step technique for robotic adrenalectomy (RA) and related modifications according to the type of adrenal mass treated. Methods: We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital (Aalst, Belgium) between January 2009 and October 2022. Demographic, intra- and post-operative, and pathological data were retrieved from our prospectively maintained institutional database. Continuous variables are summarized as median and interquartile range (IQR). Categorical variables are reported as frequencies (percentages). Results: Twenty-seven patients underwent RA were included in the study. Median age, body mass index, and Charlson's comorbidity index were 61 (IQR: 49–71) years, 26 (IQR: 24–29) kg/m2, and 2 (IQR: 0–3), respectively, and 16 (59.3%) patients were male. Median tumor size at computed tomography scan was 6.0 (IQR: 3.5–8.0) cm. Median operative time and blood loss were 105 (IQR: 82–120) min and 175 (IQR: 94–250) mL, respectively. No intraoperative complications were recorded. Overall postoperative complications rate was 11.1%, with a postoperative transfusion rate of 3.7%. A total of 10 (37.0%) patients harbored malignant adrenal masses. Among them, 3 (11.1%) had adrenocortical carcinoma, 6 (22.2%) secondary metastasis, and 1 (3.7%) malignant pheochromocytoma on final pathological exam. Only 1 (10.0%) patient had positive surgical margins. Conclusion: We described our step-by-step technique for RA, which can be safely performed even in case of high challenging settings as malignant tumors, pheochromocytoma, and large masses. The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure

Robot-assisted sutureless partial nephrectomy for the treatment of fifteen bilateral renal masses in a patient with Von Hippel–Lindau syndrome: a case report from a high-volume robotic center

: Renal cell carcinoma is among major causes of death in patients with Von Hippel-Lindau (VHL) syndrome, and it usually presents with multiple and bilateral lesions that may require multiple renal surgeries. This, in turn, may compromise renal function, resulting in end-stage renal disease. To minimize renal function impairment in these patients, great importance is given to the preservation of functional parenchyma with the use of nephron-sparing techniques. Furthermore, new techniques such as off-clamp surgery, selective suturing or sutureless techniques may improve long-term functional outcomes. We described the case of a 27-year-old male patient with a family history of VHL disease affected by multiple, bilateral renal masses. He received bilateral, metachronous robot-assisted partial nephrectomies (RAPN) for a total of 15 renal lesions. No intra- or post-operative complications occurred, and the patient was discharged on the second postoperative day after both procedures. Serum creatinine after the second RAPN was 0.99 mg/dl (baseline value was 1.11 mg/dl). In patients with VHL syndrome and multiple renal lesions, robot-assisted partial nephrectomy, especially with the use of clampless and sutureless techniques, helps minimizing renal function impairment and should be performed when anatomically and technically feasible

Improving augmented reality through deep learning : realtime robotic renal surgery instrument delineation

Several barriers prevent the integration and adoption of augmented reality (AR) in robotic renal surgery despite the increased availability of virtual three-dimensional (3D) models. Apart from correct model alignment and deformation, not all instruments are clearly visible in AR. Superimposition of a 3D model on top of the surgical stream, including the instruments, can result in a potentially hazardous surgical situation. We demonstrate real-time instrument detection during AR-guided robotassisted partial nephrectomy and show the generalization of our algorithm to ARguided robot-assisted kidney transplantation. We developed an algorithm using deep learning networks to detect all nonorganic items. This algorithm learned to extract this information for 65 927 manually labeled instruments on 15 100 frames. Our setup, which runs on a standalone laptop, was deployed in three different hospitals and used by four different surgeons. Instrument detection is a simple and feasible way to enhance the safety of AR-guided surgery. Future investigations should strive to optimize efficient video processing to minimize the 0.5-s dela

Concomitant robot-assisted laparoscopic surgeries for upper and lower urinary tract malignancies : a comprehensive literature review

Worldwide, we have witnessed an expansion of robot-assisted laparoscopic surgery (RALS) and thanks to the global adoption of high-resolution diagnostic imaging technologies, an increased incidence of newly diagnosed prostatic, renal and bladder cancers has been recorded with concurrent second primary urological cancer diagnoses increasing by 1.5%. Diverse authors have reported their findings concerning synchronous multi-visceral malignances robotic treatment within the scientific literature. The aim of this study is to comprehensively review all reported articles describing concurrent upper and lower RALS using a singular robotic port scheme within the same intervention for renal malignances and concomitant prostatic or bladder cancers. To the best of our knowledge and vigorous literature search, this is the first study that comprehensively evaluates and reports all combined upper and lower urinary tract surgeries published so far. In carefully selected patients, thanks to multidisciplinary preoperative assessment and surgical planning a combined robotic approach can reduce the morbidity, complications, hospital admissions and the overall length of hospitalization