Minimising surgical complications in patients undergoing laparoscopic and robot assisted laparoscopic pelvic surgery : description of a novel non trendelenburg patient positioning technique

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A Case of Retroperitoneal Metastases That Occur 14 Years After Surgery

Endometrial Stromal Sarcomas are rare malignant tumours of the uterus. We report the case of incidental finding of Low-Grade Endometrial Stromal Sarcoma (LGESS) that metastasized to the retroperitoneum 14 years after the original surgery in a 72-year-old woman. The patient underwent a laparotomy and excision of all tumour nodules. Considering the common recurrence of and slow growing nature of LGESS, appropriate treatment options like surgical excision and life-long follow up should be considered

The current status of MRI in prostate cancer

Background: The diagnosis and treatment of prostate cancer is a controversial topic. Until recently there has not been a reliable imaging modality for identification of cancer within the prostate. New evidence suggests that multiparametric magngenetic resonance imaging (MRI) has the potential to improve the diagnosis and treatment of prostate cancer. Objective: This article explains the potential roles for multiparametric MRI in the diagnosis and treatment of prostate cancer. Discussion: Multiparametric MRI can help identify regions which may represent clinically significant prostate cancer. MRI may also be used to guide varying prostate cancer treatment modalities. An experienced radiologist and adequately powered MRI scanner are essential. Multiparametric MRI in the hands of an experienced uroradiology team is emerging as a useful tool in the diagnosis and treatment of prostate cancer however this technology is still in its infancy and requires further evaluation. At this time prostate MRI should only be ordered by the treating urologist.6 page(s

Benign conditions that mimic prostate carcinoma : MR imaging features with histopathologic correlation

Multiparametric magnetic resonance (MR) imaging combines anatomic and functional imaging techniques for evaluating the prostate and is increasingly being used in diagnosis and management of prostate cancer. A wide spectrum of anatomic and pathologic processes in the prostate may masquerade as prostate cancer, complicating the imaging interpretation. The histopathologic and imaging findings of these potential mimics are reviewed. These entities include the anterior fibromuscular stroma, surgical capsule, central zone, periprostatic vein, periprostatic lymph nodes, benign prostatic hyperplasia (BPH), atrophy, necrosis, calcification, hemorrhage, and prostatitis. An understanding of the prostate zonal anatomy is helpful in distinguishing the anatomic entities from prostate cancer. The anterior fibromuscular stroma, surgical capsule, and central zone are characteristic anatomic features of the prostate with associated low T2 signal intensity due to dense fibromuscular tissue or complex crowded glandular tissue. BPH, atrophy, necrosis, calcification, and hemorrhage all have characteristic features with one or more individual multiparametric MR imaging modalities. Prostatitis constitutes a heterogeneous group of infective and inflammatory conditions including acute and chronic bacterial prostatitis, infective and noninfective granulomatous prostatitis, and malacoplakia. These entities are associated with variable clinical manifestations and are characterized by the histologic hallmark of marked inflammatory cellular infiltration. In some cases, these entities are indistinguishable from prostate cancer at multiparametric MR imaging and may even exhibit extraprostatic extension and lymphadenopathy, mimicking locally advanced prostate cancer. It is important for the radiologists interpreting prostate MR images to be aware of these pitfalls for accurate interpretation.14 page(s

The Effect of the modified Z Trendelenburg position on intraocular pressure during robotic assisted laparoscopic radical prostatectomy : a randomized, controlled study

Purpose: The Trendelenburg position has a dramatic effect on circulation, consequently increasing cerebral and intraocular pressure. We evaluated whether modifying the Trendelenburg position would minimize the increase in intraocular pressure. Materials and Methods: In this prospective, randomized, controlled study we compared intraocular pressure in patients undergoing robot-assisted laparoscopic radical prostatectomy while in the Trendelenburg position or the modified Z Trendelenburg position. In group 1 intraocular pressure, blood pressure and endotracheal CO₂ were measured in the patient at anesthesia induction (time 1), before positioning (time 2), and while in the Trendelenburg position (time 3) and in the modified Z Trendelenburg position (time 4). They were also measured after pneumoperitoneum (time 5), every 30 minutes (times 6 to 16), while supine at the end of pneumoperitoneum (time 17) and before awakening (time 18). We modified the Trendelenburg position by placing the head and shoulders horizontally. Results: Group 1 included 29 patients in the modified Z Trendelenburg position. Group 2 included 21 patients in the Trendelenburg position. No difference was found in patient demographics or surgical outcomes. Median intraocular pressure was in the low normal range at times 1 and 2, and increased in time 3 in each group. From time 4 intraocular pressure decreased and at all time points it was significantly lower in group 1 by a mean of 4.61 mm Hg (95% CI −6.90–2.30, p <0.001). At time 17 mean intraocular pressure decreased to normal (19.6 mm Hg) in group 1 but remained in the hypertensive range (24.9 mm Hg) in group 2. At time 18 mean intraocular pressure was 17 mm Hg in each group. Blood pressure was significantly lower in group 1 with a mean reduction in systolic and diastolic pressure of 6.3 and 4.3 mm Hg, respectively. Conclusions: Our results suggest that modifying the Trendelenburg position during robot-assisted laparoscopic radical prostatectomy has a significant positive effect on patient neuro-ocular safety by lowering intraocular pressure and accelerating its recovery to the normal range without affecting the operation.7 page(s

The Effectiveness of a Criteria-Led Discharge Initiative on the Length of Stay of Patients Who Underwent a Robotic-Assisted Laparoscopic Prostatectomy

ObjectivesTo determine the impact of a criteria-led discharge initiative (CLD) on the hospital length of stay of patients undergoing a robotic-assisted laparoscopic prostatectomy (RALP). MethodsThis is a cohort study of prospectively collected data completed at a major tertiary hospital from December 2017 to August 2020. The CLD initiative consists of 4 criteria: clinical haemodynamic stability (heart rate 100mmHg), a drain output of less than 50 mL, flatulence or bowel movement, and the ability to tolerate an oral diet. The primary outcome was hospital length of stay for patients before and after the introduction of CLD. ResultsOne hundred men undergoing RALP before the implementation of the CLD initiative were compared to 118 men undergoing RALP following the implementation of CLD. The patients had similar baseline demographic features. There was a significant difference found in hospital LOS with the pre-CLD group LOS (mean = 1.8 days, SE = 0.12) being longer than the LOS in the post-CLD group (mean = 1.4 days, SE = 0.09, P = 0.015). There were no significant between-group differences in the proportion of patients discharged on the first postoperative day and the 30-day readmission rate. ConclusionWithin our study population, we have demonstrated that the introduction of CLD was associated with reduced hospital LOS with no increase in adverse events. These findings support the need for the development of CLD in other conditions

A systematic review and meta-analysis of pelvic drain insertion after robot-assisted radical prostatectomy

Purpose To perform a systematic review and meta-analysis and to assess the clinical benefit of prophylactic pelvic drain placement following Robotic Assisted Laparoscopic Prostatectomy (RALP) with pelvic lymph node dissection (PLND) in patients with localized prostate cancer. Methods An electronic search of databases including Scopus, Medline and EMbase was conducted for articles that considered post-operative outcomes with pelvic drain placement (PD) and without pelvic drain placement (ND) after RALP. The primary outcome was rate of symptomatic lymphocele (requiring intervention) and secondary outcomes were complications as described by the Clavien-Dindo classification system. Quality assessment was performed using the Modified Cochrane Risk of Bias Tool for Quality Assessment. Results Six relevant articles, comprising 1,783 patients (PD = 1,253; ND = 530) were included. Use of PD conferred no difference in symptomatic lymphocoele rate (Risk difference 0.01; 95% CI -0.007 - 0.027), with an overall incidence of 2.2% (95% CI 0.013 - 0.032). No difference in low-grade (I - II; risk difference 0.035, 95% CI -0.065 - 0.148) or high-grade (III - V; risk difference -0.003, 95% CI -0.05 - 0.044) complications was observed between PD and ND groups. Low-grade (I-II) complications were 11.8% (95% CI 0 - 0.42) and 7.3% (95% CI 0 - 0.26), with similar rates of high-grade (III - V) complications, being 4.1% (95% CI 0.008 - 0.084) and 4.3% (95% CI 0.007 - 0.067) for PD and ND groups, respectively. Conclusion Pelvic drain insertion after RALP with ePLND did not confer significant benefits in prevention of symptomatic lymphocoele or post-operative complications. Based on these results, pelvic drain insertion may be safely omitted in uncomplicated cases following consideration of clinical factors

Bladder infusion versus standard catheter removal for trial of void: a systematic review and meta-analysis

Purpose To compare the efficacy and time-to-discharge of two methods of trial of void (TOV): bladder infusion versus standard catheter removal.Methods Electronic searches for randomized controlled trials (RCTs) comparing bladder infusion versus standard catheter removal were performed using multiple electronic databases from dates of inception to June 2020. Participants underwent TOV after acute urinary retention or postoperatively after intraoperative indwelling catheter (IDC) placement. Quality assessment and meta-analyses were performed, with odds ratio and mean time difference used as the outcome measures.Results Eight studies, comprising 977 patients, were included in the final analysis. Pooled meta-analysis demonstrated that successful TOV was significantly higher in the bladder infusion group compared to standard TOV (OR 2.41, 95% CI 1.53-3.8, p =0.0005), without significant heterogeneity (I-2 =19%). The bladder infusion group had a significantly shorter time-to-decision in comparison to standard TOV (weighted mean difference (WMD)-148.96 min, 95% CI -242.29, - 55.63, p= 0.002) and shorter time-to-discharge (WMD - 89.68 min, 95% CI - 160.55, - 18.88, p = 0.01). There was no significant difference in complication rates between the two groups.Conclusion The bladder infusion technique of TOV may be associated with a significantly increased likelihood of successful TOV and reduced time to discharge compared to standard TOV practices

A prospective, matched comparison of ultra-low and standard-dose computed tomography for assessment of renal colic : Ultra-low vs standard-dose CT for renal colic

To determine the diagnostic accuracy of ultra-low-dose computed tomography (ULDCT) compared with standard-dose CT (SDCT) in the evaluation of patients with clinically suspected renal colic, in addition to secondary features (hydroureteronephrosis, perinephric stranding) and additional pathological entities (renal masses).A prospective, comparative cohort study was conducted amongst patients presenting to the emergency department with signs and symptoms suggestive of renal or ureteric colic. Patients underwent both SDCT and ULDCT. Single-blinded review of the image sets was performed independently by three board-certified radiologists.Among 21 patients, the effective radiation dose was lower for ULDCT [mean (SD) 1.02\ua0(0.16)\ua0mSv] than SDCT [mean (SD) 4.97\ua0(2.02)\ua0mSv]. Renal and/or ureteric calculi were detected in 57.1% (12/21) of patients. There were no significant differences in calculus detection and size estimation between ULDCT and SDCT. A higher concordance was observed for ureteric calculi (75%) than renal calculi (38%), mostly due to greater detection of calculi o