How robotic surgery is changing our understanding of anatomy

The most recent revolution in our understanding and knowledge of the human body is the introduction of new technologies allowing direct magnified vision of internal organs, as in laparoscopy and robotics. The possibility of viewing an anatomical detail, until now not directly visible during open surgical operations and only partially during dissections of cadavers, has created a 'new surgical anatomy'. Consequent refinements of operative techniques, combined with better views of the surgical field, have given rise to continual and significant decreases in complication rates and improved functional and oncological outcomes. The possibility of exploring new ways of approaching organs to be treated now allows us to reinforce our anatomical knowledge and plan novel surgical approaches. The present review aims to clarify some of these issues. \ua9 2017 Arab Association of Urology

P.L.E.A.T.-Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique

OBJECTIVE: To reduce the risk of symptomatic lymphocele after robotic pelvic lymph node dissection (PLND), we present a novel technique, preventing lymphocele ensuring absorption transperitoneally (P.L.E.A.T.), where the peritoneum is "pleated" along its midline, leaving 2 lateral openings and allowing lymphatic fluid to drain away from the pelvis and into the abdomen. MATERIALS AND METHODS: We analyzed a single-surgeon series of PLNDs during robotic radical prostatectomy, comparing 195 "standard" PLNDs (in which the peritoneum was "re-approximated" or left completely open) with 176 cases in which P.L.E.A.T. was performed. RESULTS: In the group without P.L.E.A.T., 8 cases of symptomatic (grade 653, according to the Clavien-Dindo Classification) lymphoceles (4.1%) were recorded. Only 1 patient in the P.L.E.A.T. group complained of symptoms because of a lymphocele (P\u2009=\u2009.039). No patient reported complications because of the procedure. CONCLUSION: The P.L.E.A.T. technique is a fast, easy-to-perform, and safe method of reducing the risk of symptomatic lymphocele after transperitoneal robotic PLND

long delayed gross hematuria due to portal hypertension in an alcoholic cirrhotic patient with ileal conduit urinary diversion

Bleeding varices at the stomal site is an uncommon complication of ileal conduit urinary diversion in patients with portal hypertension. We describe a case with the longest delay reported in the literature, involving the onset of massive hematuria secondary to ectopic variceal bleeding in an alcoholic cirrhotic patient with external urinary ileal conduit

Athermal bladder neck dissection during robot-assisted radical prostatectomy

Introduction With improved understanding of the precise anatomy, surgical techniques during robot-assisted radical prostatectomy (RARP) have been refined, with the aim of improving functional outcomes without compromising oncological adequacy and results. Nevertheless, postoperative urinary incontinence remains a frustrating side-effect. Anatomically, bladder neck (BN) serves as an internal sphincter. The longitudinal fibres of BN may be identified and isolated with a meticulous dissection at the prostato-vesical junction, contributing to earlier return of urinary continence. The purpose of this video is to show an anatomical athermal dissection of BN during RARP.Materials and Methods After incision of endopelvic fascia and anterior defatting, the morphology of prostate not only laterally, but also at the level of bladder-prostatic junction is well visualized. With an athermal dissection of the plane between prostate and bladder we can minimize the traumatic effects on the longitudinal fibres of BN. A cold section of the preserved BN permits the complete preservation of integrity of this sphincteric structure.Results With this technique we preserve the longitudinal fibres of BN, allowing the sparing of the sphincteric mechanism of BN. The finding of a difficult athermal dissection of these plans may make you suspect the presence of an infiltration, suggesting to sacrifice BN in order to avoid a positive surgical margin. In our series no increase of PSM has been recorded using this technique.Conclusions This surgical technique preserving the natural BN mechanism appears to improve urinary continence, allowing at the same time an easy identification of a neoplastic infiltration

Frailty and elderly in urology: Is there an impact on post-operative complications?

INTRODUCTION: Frailty used as predictive tool is still not carried out in daily practice, although many studies confirm the great clinical importance of the frailty syndrome in surgical outcomes. There is no standardized method of measuring the physiological reserves of older surgical patients. The aim of this study was to analyze a cohort of older urological patients according to various frailty indices, in order to evaluate whether they are predictors of post-operative complications after urological procedures. MATERIAL AND METHODS: This is a prospective observational study on 78 consecutive older ( 6570 years) patients, subjected to major urological (both endoscopic and 'open surgical') procedures. Frailty was defined according to the Edmonton Frail Scale. Several risk models and biochemical parameters were evaluated. Post-operative outcomes were surgical and medical complications, mortality and rehospitalisation within 3 months. RESULTS: An overall prevalence of frailty of 21.8% was found. Patients with complications were frailer than those without complications (univariate analysis), considering both total patients (p = 0.002) and endoscopic (p = 0.04) and 'open surgical' patients (p = 0.013). However, in multivariate analysis, a significant correlation was not found between all frailty indices tested and the risk of major complications. Limitation of the study: the small sample size (lack of statistical power), although this is a prospective study focused on older urological patients. CONCLUSIONS: New urology-tailored pre-operative assessment tools may prove beneficial when calculating the risks/benefits of urological procedures, so that objective data can guide surgical decision- making and patient counselling. Further large clinical studies specifically focusing on elderly in urology will be needed

Effect of Hypertension on Outcomes of High-Risk Patients After BCG-Treated Bladder Cancer

Immunotherapy with Bacillus Calmette Guerin (BCG) is the most efficacious treatment for high-risk bladder cancer (BC) (Ta/T1 or carcinoma in situ) to reduce the risk of recurrence. Our aim was to evaluate whether hypertension and diabetes influence the outcome of patients with noninvasive BC treated with BCG instillations. In order to collect homogeneous data, we considered as "hypertensive" only those patients who had previous diagnosed hypertension and a history of taking medical therapy with antihypertensive drugs (AHT), and as "diabetic" only those prescribed oral antidiabetics or insulin (ADT). We analyzed 343 high-risk BC patients undergoing BCG 1995 2010) with a median follow-up of 116 months (range 48-238). The distribution of various kinds of AHT and antidiabetic drugs was homogeneous, with no significant differences (p > 0.05). In both univariate and multivariate analyses, the only statistically significant parameter propostic for recurrence after BCG treatment was AHT. Recurrence-liee survival curves showed a significant correlation with AHT (p = 0.0168, hazards ratio [HR] 1.45, 95% confidence interval [CI] 1.0692-1.9619); there was no correlation ( p = 0.9040) with ADT (HR 0.9750, 95% CI 0.6457-1.4721). After stratification of AHT and A.DT according to drug(s) prescribed, there were no significant differences in the BC recurrence rate (p > 0.05). In this study with a very long-term follow-up, hypertension alone (evaluated by AHT) revealed the increased risk of BC recurrence after BCG treatment. Several hypotheses have been formulated to support these findings, but further prospective studies are needed to both evaluate the real influence of hypertension and identify a possible prognostic factor to be used in selecting poor-prognosis BC patients as early candidates for surgical treatment

Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study

To compare the effects of CO(2) insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses

The bladder neck preservation in robot assisted radical prostatectomy: Surgical and pathological outcome

Introduction: The post-prostatectomy incontinence is influenced by multiple elements, anatomic components and biological factors. The bladder neck preservation, more accurate during robot assisted radical prostatectomy, works on two anatomic components responsible for post-prostatectomy continence. The bladder neck preservation spares the internal sphincter, which is responsible for passive continence, and results in earlier return to continence and lower rates of post-prostatectomy incontinence. Moreover, this surgical technique spares the zone of urothelium coaptation and provides primary resistance to the urine to maintain postprostatectomy continence. The potential risk of bladder neck positive surgical margins (PSM) may prevent the usage of the bladder neck preservation. Aim: The purpose of this study is to evaluate the surgical and pathological outcome in prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation. Materials and methods: Prospectively, we have collected demographic, clinical, surgical and pathological data of prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation, from January 2014 to December 2016, in Urological Clinic of the University of Padua. Moreover, it was valued the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis. Results: According to D'Amico risk classification, 40 patients (45.4%) had a low risk neoplasia, 35 patients (39.8%) had an intermediate risk neoplasia, 13 patients (14.8%) had an high risk neoplasia. The median prostatic volume, valued on specimen, was 30.84 cc (21.5-44.75 cc). The median prostatic weight, valued on specimen, was 51 gr (36-67 gr). The pathological stage of disease was pT2a in 11 cases (12.5%), pT2b in 37 cases (42.1%), pT3a in 28 cases (31.8%), pT3b in 12 cases (13.6%). The pathological stage of lymph node involvement was pNx in 17 cases (19.3%), pN0 in 66 cases (75%), pN1 in 5 cases (5.7%). The prostate cancers diagnosed had a Gleason score at specimen of 6 in 10 cases (10.4%), 7 (3+4) in 30 cases (34.1%), 7 (4+3) in 20 cases (22.7%), 8 in 19 cases (21.6%) and 9 in 9 cases (10.2%). The prostatic base was involved by neoplasia in 14 patients (15.9%); of these, 5 patients (35.7%) had bladder neck PSM. The patients with bladder neck PSM had: a pathological stage of disease as pT3a in 2 cases (40%) and pT3b in 3 cases (60%); a pathological stage of lymph node involvement as pN0 in 2 cases (40%) and pN1 in 3 cases (60%); a Gleason score at specimen of 8 in 3 cases (60%) and 9 in 2 cases (40%); multiple PSM. Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique of bladder neck preservation. Conclusions: The bladder neck preservation, during robot assisted radical prostatectomy, is a safe oncological procedure resulting in a good functional outcome, about post-prostatectomy continence, working on two anatomic components responsible for post-prostatectomy continence. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the bladder neck preservation