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Article of the week: Suture techniques during laparoscopic and robot‐assisted partial nephrectomy

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 a video produced by the authors. Please use the tools at the bottom of the post if you would like to make a comment. 

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

Suture techniques during laparoscopic and robot‐assisted partial nephrectomy: a systematic review and quantitative synthesis of peri‐operative outcomes

Riccardo Bertolo*, Riccardo Campi, Tobias Klatte, Maximilian C. Kriegmair§Maria Carmen Mir, Idir Ouzaid**, Maciej Salagierski††, Sam Bhayani‡‡, Inderbir Gill§§¶¶Jihad Kaouk* and Umberto Capitanio‡‡§§***††† On behalf of the Young Academic Urologists (YAU) Kidney Cancer working group of the European Urological Association (EAU)

 

*Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, USA, Department of Urology, University of Florence, Florence, Italy, Department of Urology, Royal Bournemouth and Christchurch Hospitals, Bournemouth, UK, §Department of Urology, University Medical Centre Mannheim, Mannheim, Germany, Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain, **Department of Urology, Bichat Hospital, APHP, Paris Diderot University, Paris, France, ††Urology Department, Faculty of Medicine and Health Sciences, University of Zielona ra, Zielona Góra, Poland, ‡‡Division of Urology, Washington University School of Medicine, St Louis, MO, §§Keck School of Medicine, USC Institute of Urology, ¶¶Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA, ***Department of Urology, San Raffaele ScientifiInstitute, and †††Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy

 

Abstract

Objective

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri‐operative outcomes after minimally invasive partial nephrectomy (MIPN).

Materials and Methods

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot‐assisted partial nephrectomy and comparative studies focused on peri‐operative outcomes were included in qualitative and quantitative analyses, respectively.

Fig. 4. Integrated overview of evidence‐based technical principles for renal reconstruction during minimally invasive partial nephrectomy and suggested standardized reporting of key renorrhaphy features in clinical studies on this topic.

Results

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon’s experience, robot‐assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non‐barbed suture. The single‐layer suture technique was associated with shorter operating and ischaemia time than the double‐layer technique. No comparisons were possible concerning renal functional outcomes because of non‐homogeneous data reporting.

Conclusions

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double‐layer suture.

 

 

 

USANZ 2018: Melbourne

G’day! The 71st  annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise.  The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases  His cases gave insight in how intraoperative complications occur and how they can be avoided.  Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation.  His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions.  One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP.  A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual  rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered  by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF.  Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell

 

Highlights from the Urological Association of Asia Annual Congress 2017

Having trained and worked in London throughout my urology career, I have recently relocated and joined the exciting, dynamic urology community of my birthplace, Hong Kong. Coincidentally, it so happens to be this year’s host of the Urological Association of Asia (UAA) annual congress #UAA2017.

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The beautiful and mesmerising night view of the Victoria Harbour of Hong Kong.

Established in 1990 in Fukuoka, Japan, the #UAA currently has 25 urological associations as members or affiliated members across Asia and Australasia with and over 25,000 members. This was my attendance at the #UAA and it most certainly did not disappoint. What made the conference even more special was the chance to meet up with my good friend and ex-colleague from Guy’s Hospital @nairajesh – both of us were honoured to speak at the meeting. With over 1600 delegates attending the meeting and over 500 scientific abstracts presented, the congress served as an excellent platform for knowledge exchange and the establishment of professional links with many urological greats in Asia and beyond.

 

Pre #UAA2017 Congress Activities

#UAA2017 started off with a pre-congress ‘wet-lab’ 3D laparoscopic skills and endourology workshop hosted by @HKUniversity and the European School of Urology @UrowebESU. Both transperitoneal laparoscopic and retroperitoneoscopic techniques were taught by eminent leaders and pioneers in minimally invasive urological surgery by faculties from Europe, India and China, including Professor Jens Rassweiller, Professor Christian Schwentner (@Schwenti1977), Dr Domenico Veneziano (@d_veneziano), Professor Janak Desai (@drjanajddesai), and Professor Zhang Shudong.

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Joint UAA-ESU 3D laparoscopic and endourological skills course faculties. Left to right: Dr Ada Ng (Hong Kong), Dr Wayne Lam @WayneLam_Urol (Hong Kong), Professor Janek Desai @drjanajddesai (India), Professor Jens Rassweiller (Germany), Professor MK Yiu (Hong Kong), Dr James Tsu (Hong Kong), Dr WK Ma (Hong Kong).

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Joint UAA-ESU 3D Laparoscopic skills workshop – Above: Professor Rassweiller (Germany) supervising overseas delegates. Below: Professor MK Yiu (Hong Kong) demonstrating techniques of laparoscopic suturing to delegates from China.

The renal cell carcinoma #RCC masterclass was a particular highlight. A whole day of excellent lectures and speakers entertained both local and international delegates, and was particularly popular with trainees. There were talks examining the role of percutaneous biopsy of renal tumours presented by Alessandro Volpe (@foxal72), an update of current trends and techniques in robotic and laparoscopic partial nephrectomy by Dr. Joseph Wong (Hong Kong) and Dr. Shuo Wang (China) and a fantastic discussion examining the role of non-clamping partial nephrectomy by Dr. Ringo Chu (Hong Kong). The afternoon session kicked off with @nairajesh giving a comprehensive review on the surgical management of advanced #RCC. Professor Axel Bex (Netherlands) continued with an examination of neoadjuvant and adjuvant systemic therapy in #RCC and the emerging role of #immunotherapy. Professor Alessandro Volpe (@foxal72) discussed the current #EAU guidelines and recent updates.

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Masterclass in #RCC: @foxal72 , @nairajesh , Professor Axel Bex (Netherlands), with moderators Dr Ringo Chu (Hong Kong) and Dr Joseph Wong (Hong Kong).

 

Day 1 of #UAA2017

The plenary session on day 1 of #UAA started off with Professor Zengnan Mo from China on the epidemiology of prostate cancer in Asia. There is, not surprisingly, a very diverse range of incidence of #prostatecancer rate across the largest continent in the world, inevitably effected by the presence of #PSA screening in countries such as Japan and Korea, ethnicity (East Asia vs Middle East), genetics (Israeli Jewish population), and their local healthcare system and policies. Arguably the currently available #prostatecancer screening trials may not be applicable to the Asian populations, and various on-going studies in Japan and China are going to address these issues. One in particular is an ongoing population-based study funded by the Chinese Ministry of Science and Technology, in which over 50,000 men will be recruited into the screening, early detection, localised, and advanced #prostatecancer cohorts and to be followed up with time. Obviously, we will not expect to see the results of the trial anytime soon, but will surely answers to address the behaviour of prostate cancer in the Asian population in the future.

Professor Sam Cheng (@UroCancerMD) from Vanderbilt University then gave a comprehensive review on the current status of #cystectomy. Robotic cystectomy appears to have the benefit of reduced blood loss and length of stay. However, long-term oncological outcome still remains uncertain, and certainly, patient reported outcome measures (PROMs) is lacking.

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Day 2 of #UAA2017

After early showers on day 2 of UAA, Hong Kong was heating up with temperatures over 33 degrees Celsius. So were the discussions in the plenary session in the morning. Professor Freddie Hamdy (@Freddie_Hamdy) gave the #EAU lecture on #activesurveillance for #prostatecancer. This was followed on nicely with the current status of #prostatecancer management in Hong Kong by Dr. Yau-Tung Chan and Dr. Gerhardt Attard (UK) enlightened the audience with a concise update in the management of hormone sensitive prostate cancer, an area where the landscape is ever-changing.

The advanced oncology session started off with a heated debate in the use of mass clamping (Dr Ringo Chu, Hong Kong) versus selective artery clamping in partial nephrectomy (Dr Tae-Gyun Kwon, Korea). Both speakers presented with very valid arguments and perhaps it was fair to say it ended up with all square. Professor Krishna Sethia (UK) gave a fascinating summary of the current local management of #penilecancer at centralised penile cancer centres in the UK, after which I was honoured to provide an update on current nodal management in #penilecancer from my recent experience at St George’s University Hospitals @StGeorgesTrust in the UK. It was exciting to see the centralisation of services in #penilecancer in the UK has given great opportunities to understand and optimise management of patients with such rare disease.

The Semi-live sessions entertained the audience on both days of the conference. Excellent videos were presented throughout. Professor Koon Rha of Yonsei University in South Korea gave a fantastic semi-live talk on his tricks and techniques of Retzius-space sparing Robot-assisted radical prostatectomy. Perhaps what’s even more exciting to know is that a Korean company has produced a new robot for surgery which has been well tested by Professor Rha’s group, which has just literally been licenced and approved in Korea just days before #UAA2017. Will this finally drive the cost of robotic surgery down? Time will tell.

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Associate Professor Declan Murphy (@declanmurphy) and Mr. Rajesh Nair (@nairajesh) both contributed with a beautiful video showcasing techniques in total pelvic exenteration and long-term outcomes of urinary diversion and reconstruction in this cohort of patients.

The Gala dinner in the evening was full of fun and entertainment. Following the performance of a soprano quartet formed by local Hong Kong urologists (who sang the classic My Way with a twist on prostate examination!), the rock stars of urology – Professor Jens Rassweiller, Dr Samuel Yee from Hong Kong, and Dr Domenico Veneziano (@d_veneziano) provided an energetic and electrifying live performance of some rock classics!

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Urology Rock N’ Roll! Left to right: Professor Jens Rassweiller (Germany), Dr Domenico Veneziano (Italy), Dr Samuel Yee (Hong Kong).

However, perhaps the highlight and the most touching moment of the evening the performance of a song written and sung by a young local former patient with a history of #ketaminebladder , who was successfully treated by the urology team lead by Professor Anthony Ng at the Prince of Wales Hospital in Hong Kong. His surgery and treatment has transformed his life – he is now enjoying a career as both a singer-songwriter of a rock band and as a footballer!

 

Day 3 of #UAA2017

The morning plenary session also saw the evergreen Dr Peggy Chu of Hong Kong, renown for her discovery of ketamine-associated uropathy and pioneered the management of this challenging 21st century urological disease.

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Left to right: Dr CW Man (Hong Kong), Congress President of #UAA2017, and Dr Peggy Chu (Hong Kong).

She delivered a very interesting talk on revisiting the role of #gastrocystoplasty. Interestingly, the operation was first described and carried out in human by the honourable Professor CH Leong at my current institution, Queen Mary Hospital @HKUniversity , in the 1970s following a successful animal study at the same institution. Its use has been limited due to its associated metabolic disturbances, but arguably it is still a weapon that can be used when tackling patients with tuberculosis-associated severely contracted bladder, in particular those who have already been rendered to have a single solitary kidney due to the disease. Another situation when #gastrocystoplasty can still be considered are those patients with #ketamine uropathy. Although patients are usually required to be completely abstinence from #ketamine abuse for a certain lengthy period of time before they are eligible for surgical treatment, many fear the avalanche effect of ileal re-absorption of the drug if an ileo-cystoplasty has been carried out in these patients, if they happen to resume ketamine use in the future. Hence, #gastrocystoplasty may be a better substitution tissue for cystoplasty in the management of such patients.

The meeting also provided an opportunity to catch up with fellow Guy’s Hospital urology graduates @nairajesh and @declanmurphy over a cold pint of Hong Kong locally made #MoonzenBeer, when the temperature outside the conference centre was hitting 34 degrees Celsius!

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Left to right: Dr Wayne Lam (Hong Kong), Mr Rajesh Nair (Australia/United Kingdom), A/Prof Declan Murphy (Australia).

All credits to #UAA and the local organisers’ immense effort and hard work, making this congress a valuable learning experience for everyone who participated. We very much look forward to #UAA2018. Bring on Kyoto, Japan!

 

 

Wayne Lam

Assistant Professor in Urology, Queen Mary Hospital, University of Hong Kong

Twitter: @WayneLam_Urol

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Rajesh Nair

Fellow in Robotic Surgery and Uro-Oncology

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Article of the Week: LCA – EuRECA study

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.

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

Oncological outcomes and complication rates after laparoscopic-assisted cryoablation: a European Registry for Renal Cryoablation (EuRECA) multi-institutional study

Tommy K. Nielsen*, Brunolf W. Lagerveld, Francis Keeley, Giovanni Lughezzani§Seshadri Sriprasad, Neil J. Barber**, Lars U. Hansen*,††, Nicole M. Buf§Giorgio Guazzoni§, Johan A. van der Zee, Mohamed Ismail, Khaled Farrag,Amr M. Emara**,‡‡, Lars Lund††,§§, Øyvind Østraat* and Michael Borre*

 

*Department of Urology, Aarhus University Hospital, Aarhus, Denmark, Department of Urology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, Bristol Urological Institute, Bristol, UK, §Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Milano, Rozzano, Italy, Department of Urology, Darent Vally Hospital, Dartford, **Department of Urology, Frimley Park Hospital, Camberley, UK, ††Department of Urology, Odense University Hospital, Odense, Denmark, ‡‡Department of Urology, Ain Shams University, Cairo, Egypt, and §§Department of Urology, Viborg Regional Hospital, Viborg, Denmark

 

Abstract

Objective

To assess complication rates and intermediate oncological outcomes of laparoscopic-assisted cryoablation (LCA) in patients with small renal masses (SRMs).

Patients and Methods

A retrospective review of 808 patients treated with LCA for T1a SRMs from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien–Dindo classification. Kaplan–Meier analyses were used to estimate 5- and 10-year disease-free survival (DFS) and overall survival (OS).

aotw-mar-2-2017

Results

The median [interquartile (IQR)] age was 67 (58–74) years. The median (IQR) tumour size was 25 (19–30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy-confirmed renal cell carcinoma (RCC) were available for survival analyses. The median (IQR) follow-up for the RCC-cohort was 36 (14–56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5-/10-year DFS was 90.4%/80.0% and 5-/10-year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥III) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32–6.20; P = 0.005).

Conclusions

This large series of LCA demonstrates satisfactory long-term oncological outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.

Editorial: Laparoscopic renal mass cryoablation: an operation in search of an indication

In this issue of BJUI, Nielsen et al. [1] report the oncological and surgical outcomes from a multi-institutional cohort of patients receiving laparoscopic cryoablation (LCA) as primary therapy for solitary renal masses <4 cm in size (cT1a). This work represents the latest addition to a growing body of literature in an important oncological space that lacks prospective/randomized evidence to guide practitioners counselling patients with kidney cancer. Although the article does not advance the discussion toward higher levels of evidence, the results are nonetheless provocative and several strengths and weaknesses deserve comment.

While nephron-sparing surgery has become the recognized standard of care for cT1a renal lesions [2, 3], the reality remains that certain patients carry unacceptable risk profiles for partial nephrectomy, making less invasive options preferable. Such indications might include being elderly or frail, having hereditary kidney cancer syndromes prone to metachronous renal tumours, or having a solitary kidney. For such patients, focal renal mass ablative techniques have emerged as a safe alternative to extirpation that avoids the permanent nephron loss associated with radical nephrectomy. From an oncological perspective, however, cryotherapy, radiofrequency ablation and microwave ablation (by any approach) all have yet to be studied against partial nephrectomy in a prospective fashion. Numerous retrospective analyses have attempted to fill the void [4], yet the general consensus among most academic kidney surgeons is that renal mass ablation offers acceptable but inferior cancer control compared with surgery [5].

In this retrospective analysis by Nielsen et al., 808 patients underwent LCA between 2005 and 2015, 514 (63.4%) of whom had pre-procedural biopsy-proven RCC. The principal findings described in the present study include not only 5- and 10-year disease-free and overall survival, but also morbidity and mortality outcomes after LCA. The authors should be commended for the structure of their design, which included a high proportion of patients with available preoperative biopsy data. Additionally, clear definitions of treatment success, ‘residual unablated tumour’ and ‘local tumour progression’ are provided, and consistent follow-up imaging protocols were employed by the institutions involved. In each of these ways, Nielsen et al. overcome many of the pitfalls that have clouded the interpretation of results from previous reports.

Nevertheless, the oncological outcomes reported in this study, which are on a par with those for partial nephrectomy as well as other ablative techniques, must be approached with a degree of skepticism. As there is no alternative treatment cohort included in the study, omission of anatomical complexity data (in the form of nephrometry scoring) prohibits any meaningful comparison with patients having undergone ablative procedures or partial nephrectomy from other series. Availability of these data is essential for the reader to gauge the influence of selection bias in the interpretation of the results.

From a morbidity and mortality standpoint, the reported 16% overall complication rate, 3% rate of severe complications (defined as Clavien III–V) and three deaths within 30 days of the procedure might have been strengthened by the missing nephrometry data, as the rate of complications would be expected to increase with the complexity of the renal mass [6]. Also noticeably absent from the analysis are granular comorbidity and previous surgery data, both of which intuitively predispose patients to complications when undergoing minimally invasive surgery.

With these limitations in mind, the experienced kidney surgeon is not likely to see LCA as an equally effective or safer alternative to minimally invasive partial nephrectomy, which can be performed with similar complication rates and length of hospital stay without sacrificing oncological efficacy in most patients. Similarly, the question of why the practitioner should assume the risks of LCA when percutaneous cryoablation is readily available at many contemporary kidney cancer centres is unanswered by the present study. Indeed, with increasingly complex renal masses being managed via minimally invasive nephron-sparing surgery, and active surveillance of small renal masses gaining traction in the appropriate patient population, cryoablation via a laparoscopic approach unfortunately may represent another urological application without a well-defined indication going forward. We hope that the results presented by Nielsen et al. in this issue of BJUI encourage investigators to enroll patients in prospective trials aimed at comparing available ablative techniques or partial nephrectomy in matched cohorts to identify the ideal patient population for this operation and further clarify the oncological and clinical outcomes compared with surgical excision.

Daniel C. Parker and Brian W. Cross

 

Department of Urologic Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City, OK, USA

 

 

References

 

1 NielsenT, Lagerveld B, Keeley F et al. Oncologic outcomes and complication rates after laparoscopic-assisted cryoablation: a EuRECA multi-institutional study. BJU Int 2016. [Epub ahead of print].

 

2 Campbell SC, Novick AC, Belldegrun A et al. Guideline for management of the clinical T1 renal mass. J Urol 2009; 182: 12719

 

3 Ljungberg B, Bensalah K, Caneld S et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015; 67: 91324

 

4 Wagstaff P, Ingels A, Zondervan P et al. Thermal ablation in renal cell carcinoma management: a comprehensive review. Curr Opin Urol 2014; 24: 47482

 

5 Kutikov A, Smaldone MC, Uzzo RG. Focal therapy for treatment of the small renal mass: dealers choice or a therapeutic gamble? Eur Urol 2015; 67: 2601

 

 

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.

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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 

 

Laparoscopy and robotics – an overhyped rivalry?

Highlights from the Laparoscopy & Robotics subspecialty meeting at the 50th annual conference of the Urological Society of India (Mumbai, India)

It was like Australia and Egg2ngland playing a friendly cricket match in the middle of the Ashes tour…or perhaps Liverpool and Manchester United fans celebrating together in the spirit of bonhomie…

In an ably conducted sub specialty meeting during the golden jubilee annual conference of the Urological Society of India, Dr. Mallikarjuna Chiruvella from Hyderabad, the hub of the Indian software revolution, brought together traditional rivals, Laparoscopy and Robotics – not for comparisons and conflicts – but to find common ground in terms of improving outcomes and handling complications.

Undoubtedly, there is a lot in common when it comes to these two modalities. Indeed one is the progeny of the other. The anatomy, approach, indications, complications, and indeed, the ways of dealing with them have more similarities than differences.  Experts from both sides of the fence highlighted these similarities and delved into the finer technical points of these modalities across the wide spectrum of urological ailments – urolithiasis, reconstructive urology and urologic oncology.  An important component was the special emphasis on laparoscopic training and suturing techniques.

Our very own Editor In Chief, Prof. Prokar Dasgupta, was the show stopper with an exciting talk on the future of robotic surgery in which he explored advancements related to imaging integration, in vivo microscopy, automation, virtual reality and haptic feedback in the next gen robotic systems of the future.

Video clip of Prof Dasgupta’s slides (no audio).

Sub specialty convener, Dr Mallikarjuna and co conveners, Dr Arvind Ganpule from Nadiad, Gujarat and Dr. Gagan Gautam from New Delhi managed to raise some goosebumps in the 500+ attendees by presenting 3 ‘nightmares’ video sessions which took a keen look at intraoperative disasters and ways and means of preventing and managing them.

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While the debates on laparoscopy versus robotics continue, the content and conduct of the meeting ensured that everyone could take away something practical and implementable from this session. Here’s to the new found common ground!

 

Gagan Gautam Head – Urologic Oncology & Robotic Surgery, Max Institute of Cancer Care, New Delhi, India. Twitter: @DrGaganGautam

Dr. Mallikarjuna Chiruvella Managing director, Asian Institute of Nephrology and Urology, Erramanzil colony, Hyderabad, India

 

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

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

 

 

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.

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

 

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

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

 

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

 

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