Tag Archive for: open surgery

Posts

Should we abandon live surgery: reflections after Semi-Live 2017

Prokar_v2Ever since 2002, I have performed live surgery almost every year where it is transmitted to an audience eager to learn. This year I was invited by Markus Hohenfellner to the unique conference, Semi Live 2017 in Heidelberg. To say that it was an eye opener is perhaps stating the obvious. One look at the program will show you that the worlds most respected Urological surgeons had been invited to participate, but with a difference. There was no live surgery. Instead videos of operations – open, laparoscopic and robotic were shared with the attendees “warts and all” as a learning experience. These were not videos designed to show the best parts of an operation. There were plenty of difficult moments, do’s and don’ts and troubleshooting, but all this was achieved without causing harm or potential harm to a single patient.

My highlights were laparoscopic sacrocolpopexy (Gaston), robotic IVC thrombectomy up to the right atrium (Zhang) and reconstructive surgery for the buried penis (Santucci). The event takes place every 2 years and the videos are all available on the meeting app which can be downloaded here and is an outstanding educational resource.

We were treated to a heritage session which included the superstars Walsh, Hautmann, Clayman, Mundy, Schroder and Ghoneim. This was followed by our host Markus Hohenfellner comparing and contrasting the art of Cystectomy and reconstruction by Ghoneim, Stenzl and Studer.

 

Open surgery is certainly not dead yet. The session ended with Seven Pillars of Wisdom from Egypt which turned out to be a big hit on Twitter.

capture

The editor’s choice session, a new innovation for 2017, allowed me to showcase the Best of BJUI Step by Step, a section that has now replaced Surgery Illustrated with fully indexed and citable HD videos and short papers.

Has live surgery had its day?

Many on Twitter seemed to agree that in 20 years time we might look back and say that it was not the right thing to do.

1-1

1-2

Surgeons do not operate “live” every day. Most doctors in a survey, would not subject themselves or their families to be patients during live surgery. Talk about hypocrisy!! Why should it be any different for our patients? Live surgery is NOT a blood sport practised in Roman times….

The counterpoint is that patients often have the services of the best surgeons during live surgery, recorded, edited videos are not quite the same and that the whole affair has become safer thanks to patient advocates and strict guidelines from some organisations like the EAU. Others have banned the practice for good reason. While the debate continues, I for one came away feeling that Semi-Live was as educational, less stressful and much safer for our patients.

 

Prokar Dasgupta @prokarurol
Editor-in-Chief, BJUI 

 

Article of the Week: International Consultation on Urological Diseases and EAU International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

 

Mark W. Ball*, Ashok K. Hemal† and Mohamad E. Allaf*

 

*James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, and Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA

 

Read the full article

Abstract

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the ‘gold standard’. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

 

aotwjan3-reults

 

Read more articles of the week

 

Editorial: Laparoscopic adrenalectomy – the ‘gold standard’ when performed appropriately

Since its development 25 years ago, laparoscopic adrenalectomy (LA) has played a major role in the management of adrenal diseases. The guideline by the International Consultation on Urological Diseases-European Association of Urology (ICUD-EAU) International Consultation on Minimally Invasive Surgery in Urology, published in this month’s issue of BJUI [1], will further expand the appropriate use of LA to a majority of patients.

After the development of laparoscopic nephrectomy in 1990, the idea of LA was conceived by several urologists and endocrine surgeons. The first LA was performed by Go et al. [2] in January of 1992 in Japan, and the first results were published by Higashihara et al. [3] in July 1992, followed by results from Gagner et al. [4] in October 1992 [4].

Nowadays, almost all clinical guidelines strongly recommend laparoscopic surgery as the ‘gold standard’ approach to non-invasive small benign adrenal tumours. Even though there are no prospective randomized studies comparing laparoscopic and open adrenalectomies, there is a consensus that LA is associated with less postoperative pain, earlier recovery and similar long-term outcomes compared with open surgery. The conclusion in the present guideline is very acceptable.

Many comparative studies also support LA for pheochrmocytoma; however, a great concern is capsular injury during the operation. The incidence of malignancy in pheochromocytoma is >10%, and tumour spillage during laparoscopic surgery has been reported in the literature [5]. Avoiding capsular injury during adrenal surgery is very important, not only for pheochromocytoma, but also for all adrenal tumours. Even if the preoperative diagnosis is adrenocortical adenoma, some tumours could be adrenocortical cancer, especially when the tumour is >4 cm in diameter. Because the incidence of malignancy in paragangliomas is much higher, it is recommended that paragangliomas be resected by open surgery [6]. For small, non-invasive paragangliomas in surgically favourable locations, laparoscopic surgery could be an option based on the surgeon’s experience.

Indications for LA for malignant tumours is a matter of debate. It depends purely on the surgeon’s experience. The European Society for Medical Oncology Clinical Practice Guidelines for adrenal cancer in 2012 recommend LA as a safe and effective procedure for a select group of patients with small adrenocortical cancers without preoperative evidence of invasiveness. Small non-invasive metastatic adrenal tumours are also candidates for laparoscopic surgery. Most importantly, standard principles of oncological surgical treatment should be strictly respected, and open conversion is warranted when difficult dissection is encountered such as in cases of tumour adhesion or invasion or enlarged lymph nodes.

With regard to the laparoscopic approach to the adrenal tumour, the transperitoneal approach makes it easier to understand the surgical anatomy and may be suitable for less experienced surgeons when compared with retroperitoneal approaches; however, in cases when the transperitoneal approach is not suitable because of previous abdominal surgery, retroperitoneal approaches should be selected. As described in this guideline for the retroperitoneal approaches, the posterior approach has been reported frequently in the literature, with similar peri-operative outcomes to those of the transperitoneal approach. The posterior approach is unique, however, because of the prone position of the patient, and surgeons are required to have an understanding of anatomy in the prone position. The majority of urologists are more familiar with the lateral retroperitoneal approach, which is widely used for laparoscopic nephrectomy.

In conclusion, minimally invasive surgery, including laparoendoscopic single-site surgery and robot-assisted surgery, is desired by patients with adrenal diseases. In the USA, 60% of adrenalectomies are performed by urologists, while the rest are performed by endocrine surgeons [7]. Appropriate indications for and skilled performance of LA or robot-assisted adrenalectomy are critical if urologists are to be selected by endocrinologists and patients.

Read the full article
Tadashi Matsuda, President of the Endourological Society
Department of Urology and Andrology, Kansai Medical University, Hirakata, Japan

 

References

 

 

2 GoH, Takeda M, Takahashi H et al. Laparoscopic adrenalectomy for primary aldosteronism: a new operative method. J Laparoendosc Surg 1993; 3: 4559

 

3 Higashihara E, Tanaka Y, Horie S et al. A case report of laparoscopic adrenalectomy. Nihon Hinyokika Gakkai Zasshi 1992; 83: 11303

 

4 Gagner M, Lacroix A, BolteE. Laparoscopic adrenalectomy in Cushingsyndrome and pheochromocytoma. N Engl J Med 1992; 327: 1033

 

LiML, Fitzgerald PA, Price DC, Norton JA. Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy. Surgery 2001; 130: 10727

 

6 Lenders JWM, Duh Q-Y, Eisenhofer G et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99: 191542

 

7 Monn MF, Calaway AC, Mellon MJ et al. Changing USA national trends for adrenalectomy: the inuence of surgeon and technique. BJU Int 2015; 115: 28894

 

© 2024 BJU International. All Rights Reserved.