The Incidence and Management of Pleural Injuries Occurring during Open Nephrectomy

Objective. To evaluate the incidence, management, and risk factors of pleural injuries occurring during open nephrectomy. Methods. Between June 2004/and June 2008, 165 patients (167 renal units) underwent open simple (n = 37, 22.2%), partial (n = 39, 23.4%) or radical (n = 91, 54.5%) nephrectomy in our institution. Results. Flank, Chevron, and abdominal midline incisions were used in 148(88.6%), 17(10.2%), and in 2(1.2%) surgical procedures, respectively. Ribs were excised in 109(65.3%) procedures (11th rib, 10th-11th ribs, and 11th-12th ribs). Intraoperative pleural injuries were detected in 20(12%) procedures, 16(80%) were treated successfully with simple evacuation technique, and 4 required chest tube insertion. Age, sex, surgery type, incision type, and surgery site were not associated with pleural injury occurrence (P > .05). Rib resection was the only parameter associated with pleural injury occurrence. Conclusion. Pleural injuries occur in 12% of open nephrectomy procedures, and 80% can be repaired successfully. Few of them (2.4%) need chest tube insertion. Performing rib resection is a significant risk factor for pleural injury occurrence during nephrectomies

The role of collecting bladder wash fluid before biopsy procedure to help the cytological diagnosis of residual tumor

Background: Urinary cytology has low sensitivity and specificity in urinary neoplasm. Aim: We planned to assess whether the examination of bladder washing before biopsy (WBB) plays a role in better cytologic diagnosis of bladder wash fluid collected after biopsy procedure (WAB) in papillary urothelial neoplasms. Materials and Methods: We included 36 patients with papillary lesion of bladder. Prior to the biopsy, the bladder is washed and fluid is collected for cytology; later transurethral resection (TUR) is performed, then bladders are washed again and the fluid is separately collected for cytology. Both fluids were centrifuged and stained with May-Grünwald Giemsa (MGG). First the WAB slides were evaluated and diagnosed. After evaluation of the WBB slides, the WAB slides were rediagnosed. Presence of cellularity, papillary structure, fusiform cells, background bleeding, and cytolysis in WBB and WAB were evaluated separately. Results: We determined that 31 WBB samples were hypercellular, and 12 of them remained as hypercellular in WAB. Papillary structures were observed in 20 WBB samples; and in one WAB cytology. In 29 cases where no fusiform cells are identified in WBB, 22 showed fusiform cells in WAB. Cytolysis in WABs was noted in 15 cases whose WBBs did not show cytolysis. The decrease in cellularity, papillary structure (P < 0.001, both), cytolysis (P = 0.008), and fusiform cells (P < 0.001) were statistically significant. After seeing the WBB slides, we reevaluated the WAB slides. Out of the eight out of 36 (22.2%) samples diagnosed with degeneration previously, five (62.5%) samples were rediagnosed as benign, two (25%) as cytologic atypia which favor reactive, and one (12.5%) as malignant. Conclusion: Due to the better quality, initial evaluation of WBB may help more effective diagnoses of WAB slides

Does the experience of the bedside assistant effect the results of robotic surgeons in the learning curve of robot assisted radical prostatectomy?

ABSTRACT Introduction: The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP. Materials and Methods: We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately. Results: There were no significant differences between the groups in terms of age, comorbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min, p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively). Conclusion: Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time

Outcomes of Robotic Radical Prostatectomy in High-risk Prostate Cancer Patients: Experience in 60 Patients with Oncological and Functional Outcomes

Introduction: In this retrospective study, we report outcomes of robot-assisted laparoscopic radical prostatectomy (RARP) in high-risk prostate cancer (HRPC), classified according to the D’Amico risk criteria and with a minimum follow-up of 1 year. Methods: A total of 60 patients who had at least one preoperative HRPC feature and underwent RARP were included. Mean patient age and preoperative serum prostate-specific antigen level were 66.4±7.5 years and 13.4±11.0 ng/ml, respectively. Preoperatively, 3 (5.0%), 4 (6.7%), 17 (28.3%), 3 (5.0%), and 33 (55.0%) patients had prostate biopsy-proven Gleason scores of 5+4, 4+5, 4+4, 3+5, and <8, respectively. Bilateral neurovascular bundle (NVB)-sparing, unilateral NVB-sparing, and non-NVB-sparing surgery were performed in 44 (73.3%), 3 (5.0%), and 13 (21.7%) patients, respectively. Results: Mean console time, intraoperative blood loss, duration of hospital stay, and urethral catheter removal time were 159.7±62.4 minutes, 210±201.9 ml, 3.9±1.9 days, and 10.9±5.3 days, respectively. During the perioperative period (Days 0-30), 7 minor and 5 major complications occurred as categorised using the modified Clavien classification. No complications were detected during postoperative Days 31-90. Postoperative pathological stages included pT0, pT2a, pT2b, pT2c, pT3a, and pT3b disease in 2 (3.3%), 8 (13.3%), 4 (6.7%), 14 (23.3%), 18 (30.0%), and 14 (23.3%) patients, respectively. The positive surgical margin rate was 26.7% and mean lymph node yield was 11.8±8.3 (range: 3-37). Mean follow-up was 27.8±11.1 months. Biochemical recurrence was detected in 13 (21.7%) patients. Of the total 60 patients, 26 (43.3%) were fully continent (0 pad/day), 15 (25.0%) wore a safety pad/day, 10 (16.7%) wore 1 pad/day, 5 (8.3%) wore 2 pads/day, and 4 (6.7%) wore >2 pads/day. Of the 27 patients with no preoperative erectile dysfunction (ED), 17 (63.0%) had no ED at a mean follow-up of 1 year. Trifecta and pentafecta rates were 43.2% and 28.7%, respectively. Conclusion: Based on our experience, RARP in HRPC is a relatively safe procedure with satisfactory oncological and functional outcomes

Robotic-assisted Laparoscopic Transperitoneal Adrenalectomy: Outcomes of Initial Five Patients

Objective: To report the outcomes of transperitoneal robotic adrenalectomy (RA) procedures in five initial cases performed at two institutions. Methods: Between March 2012 and November 2014, five patients underwent RA. A transperitoneal approach was taken by using the da Vinci-S four-arm surgical robot. Outcomes were assessed retrospectively. Results: Mean patient age was 42.6±5.1 (range: 34-47) years. Mean body mass index was 30.5±4.5 (range: 23.2-35.2) kg/m². Median tumour size detected on radiological imaging was 3.1±1.7 (range: 1.2-6.0) cm. Mean operation time was 129.0±12.4 (range: 120-150) minutes and median estimated blood loss was 100.0±119.3 (range: 50-350) ml. No intraoperative or perioperative complications occurred according to the modified Clavien complication scale. Median duration of hospital stay was 2.0±1.7 (range: 2-6) days. The fourth robotic arm was used in two patients. Histopathology results demonstrated: metastasis of renal cell carcinoma occurred in 1 case, adrenal cortical adenoma in 2 cases, pheochromocytoma in 1 case, and hyperplasia in 1 case. After a median follow-up of 17.0±15.0 (range: 3-40) months, no local recurrence was detected. Conclusion: RA is a safe minimally invasive surgical approach that has excellent surgical and oncological outcomes in the treatment of adrenal masses <7 cm in size

Learning Curve of Robotic Radical Prostatectomy

Introduction: Prostate cancer (PrC) is the fifth most common malignancy worldwide and the second most common malignancy in men. Currently, robotic-assisted laparoscopic radical prostatectomy (RARP) has become a popular treatment for localised PrC treatment worldwide. We aimed to assess the learning curve of RARP in our institution. Methods: A total of 391 patients who underwent RARP in our clinic between February 2009 and April 2013 were included in the study. We retrospectively evaluated patient data that were recorded prospectively. The demographic, perioperative, postoperative functional, and oncological results of six surgeons’ patient groups (n=72, n=110, n=103, n=38, n=36, and n=32) and three consecutive series formed by dividing the patient groups of the three surgeons with the highest volume of cases were analysed. Results: There was no significant difference between patient groups with regard to age, American Society of Anesthesiologists score, preoperative International Prostate Symptom Score, International Index of Erectile Function (IIEF) score, number of previously performed operations, prostate-specific antigen levels, clinical stage, biopsy pathology, pathological stage, positive surgical margin (PSM) rate, biochemical recurrence (BCR) rate, potency, and continence rate at postoperative Month 12. When we assessed the three consecutive series of the three highest-volume surgeons we found that, over time, operation time (OT) decreased significantly (p0.05), and median IIEF score at 12 months improved significantly (p0.05), and median IIEF score at 12 months improved significantly (p=0.01) in the series of Surgeon 2; OT decreased significantly (p0.05 for both) in the series of Surgeon 3. The overall complication rate was 11.7% and 34% of these complications were major ones. The overall blood transfusion rate was 2%. The overall PSM rate was 20.4% (9.3% for pT2 tumours and 44% for pT3 tumours). The overall rate of BCR was 9.4%. Conclusion: In our clinical experience, OT, EBL, and blood transfusion rate seem to decrease during the learning curve of RARP