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RSM Urology Winter Meeting 2017, Northstar, California

rsm-2017-blogThis year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine.  We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

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On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

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With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

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We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

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A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

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In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

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Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

 

A Rather Nasty Surprise

Recently, I encountered, and indeed I actually caused, a complication of robot-assisted radical prostatectomy (RARP) which was new to me, and one which I felt that I should share with other surgeons.

PM, a 60-year old teacher, underwent a completely routine RARP, which took less than 2 hours to perform on a Saturday morning. During Sunday night he developed severe abdominal pain and distension. By Monday morning he was in distress with rebound tenderness and marked tachycardia. A CT scan was requested, which revealed a caecal volvulus. A laparotomy by a general surgeon confirmed the diagnosis and an urgent right hemicolectomy was undertaken. The patient made an uneventful recovery and, I am pleased to say, is still speaking to me. Histology confirmed an ischaemic caecum twisted on its rather thickened mesentery, with no perforation present. The prostate itself contained a Gleason 3+4=7 adenocarcinoma, without evidence of extra-prostatic extension.

Although robotic assistance provides the benefits of very precise, virtually bloodless surgery, with 10 times magnification and 3D vision, it also carries the risk of a specific set of complications. These need to be dealt with promptly and efficiently and can usually be completely resolved. Failure to recognise post-operative problems, such as bowel injury, intra-abdominal bleeding or port-site hernia, however, can place the patient in severe and increasing jeopardy. We recently published an article in the BJUI entitled “Lessons Learned from 1000 robot-assisted radical prostatectomy” in which we discussed how many of the problems could be avoided, and, if they occur how they can be best dealt with. One key message is the importance of an early CT scan to diagnose the nature of a post-operative problem, rather than crossing fingers and hoping things will settle.

I am hoping that this blog, and the BJUI article mentioned above, will stimulate other surgeons to discuss openly and frankly the problems that they themselves have encountered, either with regular laparoscopy or with the da Vinci robot, and how they dealt with them. Learning the lessons, not only from one’s own errors and omissions, but also from those of others, seems the best way to become, and continue to be, a safe and successful surgeon.  

 

Roger Kirby, The Prostate Centre, London

Article of the week: Nerve sparing during RARP: Watch the weaker hand

Every week the Editor-in-Chief selects the 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.

Pathological confirmation of nerve-sparing types performed during robot-assisted radical prostatectomy (RARP)

Woo Jin Ko, Gregory W. Hruby*, Andrew T. Turk, Jaime Landman‡ and Ketan K. Badani*

Department of Urology, National Health Insurance Corporation Ilsan Hospital, Goyang, South Korea; Departments of *Urology and Pathology, Columbia University Medical Center, New York, NY, and Department of Urology, University of California Irvine, Irvine, Orange, CA, USA

Read the full article
OBJECTIVES

• To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens.

• To aid the novice robotic surgeon to develop the skills of RARP.

PATIENTS AND METHODS

• Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated.

• Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15° intervals (3–9 o’clock position), measured as the distance between the outermost prostate gland and surgical margin.

• The slides were reviewed by an experienced uropathologist who was ‘blinded’ to the NST.

RESULTS

• In all, 93 men were included. The overall mean (SD) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001).

• FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW.

• Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon’s right-hand dominance.

• Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively.

• To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required.

CONCLUSIONS

• The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right.

• The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF.

 

Read Previous Articles of the Week

Editorial: Specimen fascia width reflects nerve-sparing technique

The authors have reported a pathological analysis showing that various levels of nerve-sparing technique were reflected in the radical prostatectomy (RP) specimen. Intriguingly, the authors found that the fascia width on the left side was much wider than the right side in the RP specimen with the interfascial nerve-sparing technique. This is important information for robotic surgeons. Looking at the literature, almost twice as many positive surgical margins have been reported on the left side in patients treated with laparoscopic RP and robot-assisted RP (RARP). Secin et al. also reported similar results, which revealed the tendency for left-side dominance of positive surgical margins. These results seem to be in large part due to the left side being more technically challenging, resulting in less precise dissection.

For lymph node dissection, our own unpublished data of 1005 patients who underwent RARP indicates that the mean lymph node yield is higher on the left side (7.5 vs 7.1, P = 0.004), while the author’s previous study found a higher lymph node yield on the right side. Although, we could not establish which factors contributed to the contrary results, it seems that side preference also exists when performing robotic lymph node dissection.

While the da Vinci Surgical System® has been shown to eliminate innate hand dominance, the observed findings were of novice robotic surgeons and meticulous dissection of the neurovascular bundle is usually performed using a dominant hand even in experienced robotic surgeons. Moreover, differences in robot instruments of both arms and assistant positioning may also play a role in different outcomes by laterality. Nevertheless, the da Vinci Surgical System provides surgeons with magnified three-dimensional vision equally on both sides and promotes meticulous lateral dissection. We think that the imprecision of surgery on the left side could be overcome if surgeons are aware of the potential difference in laterality. Finally, we congratulate Ko et al. for their novel work. A follow-up study with multiple surgeons and analysis that reflects the effect of the surgeon’s learning curve on the outcomes would also be informative.

Kwang Hyun Kim and Koon Ho Rha
Department of Urology, Yonsei University College of Medicine, Seoul, Korea

Read the full article

Anaesthesia for robotic-assisted laparoscopic radical prostatectomy

Richard MoreyHere’s my technique for anaesthetising patients for robotic-assisted laparoscopic radical prostatectomy and I’d be interested to hear any thoughts, comments and ideas.

Pre-op. I try to fast the patients for as short a time as possible and also include pre-operative carbohydrate loading. This is in line with Enhanced Recovery After Surgery (ERAS) Guidelines for major bowel surgery and has been shown to reduce the negative nitrogen balance that occurs following major surgery. I use 200ml cartons of Polycal, which is clear and non-particulate, prescribed 12 and 3 hours pre-operatively. Clear fluids are encouraged up to 2 hours pre-op as this improves gastric emptying and minimises pre-operative dehydration.

Intra-op. I use a mixed technique of both general and regional anaesthesia. The general consists of a fairly standard technique with a Propofol induction and maintenance with Desflurane and a Remifentanil infusion. To reduce post-operative nausea and vomiting I use ondansetron, cyclizine and dexamethasone. The regional part is a spinal anaesthetic using 0.5% Hyperbaric Bupivacaine with additional intrathecal Diamorphine. Regional anaesthesia has been shown to reduce peri-operative DVT formation, probably by blocking sympathetic activity and improving blood flow through the legs, it also produces profound muscular relaxation enabling better pelvic vision and easier insufflation. In addition there is some evidence that appears to suggest regional anaesthesia may reduce the recurrence rate of prostate cancer. As the patients are positioned in a steep trendelenberg they are all intubated and ventilated with a small amount of additional PEEP to reduce pulmonary atelectasis.

Post-op. Intrathecal diamorphine usually provides 12-14 hours of good quality post operative analgesia. Intrathecal opiates act locally producing segmental analgesia and therefore do not produce the systemic side effects to the same degree as intravenous opiates. The ondansetron given peri-operatively may reduce the incidence of opiate induced pruritus as well as acting as an excellent antiemetic. Additional analgesia will be required but usually paracetamol and ibuprofen are sufficient. It is unusual for patients to require any additional stronger opioid medications and this is helpful in ensuring that gastric stasis and reduced gut motility do not occur. This enables the patients to be rapidly progressed on to a light solid diet that in turn further reduces the occurrence of a post-operative ileus.

Fluid Management. Using this starvation policy, patients should commence their surgery with only a minimum degree of dehydration. Remifentanil produces an extremely cardio-stable anaesthetic and with the patients being head down peri-operative hypotension is unusual.  Should this however occur blood pressure should be maintained with the judicial use of vasopressors and fluid if necessary. Post-operative urine output can be maintained if required with plasma expanders and diuretics.

 

Richard Morey qualified from MHMS in 1987 and has been a Consultant Anaesthetist in SE London since 1997. His particular interests are ERAS/ Laparoscopic Surgery along with ENT and Difficult Airways.

@morphthegasman

 

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What prophylactic steps should we take to prevent DVT/PE after RARP?

Deep vein thromboses (DVT) and pulmonary embolism (PE) are rare, but potentially devastating, complications of major pelvic surgery. We have performed more than 1000 robot assisted radical prostatectomy (RARP) procedures in Central London (Lessons learned from 1000 RARP operations BJUI 2013;111(1):9-10.) and to date encountered just a couple of DVTs, as well as a single, non-fatal instance of PE. However, in the case of one of us (RK), a close relative passed away as a result of a PE 10 days after a routine hip replacement performed in Oxford, a very sad event which highlighted the very negative impact on the family of this preventable surgical complication.

Guidance from NICE recommends that evidence-based steps be taken to reduce the risk of venous thromboembolism (VTE). Failure to do so therefore renders us open to criticism if a DVT, or worse a PE, does develop. On the other hand, pelvic haematoma and haematuria are troublesome complications of RARP, the risks of which may be exacerbated by anticoagulation.

What therefore should we be doing to reduce the risk of before and after laparoscopic pelvic surgery? Few would disagree that TED stockings should be worn before and after surgery, but how long should they be retained, as many patients do find them rather uncomfortable? Calf compression boots during surgery and for 12 hours or so post-operatively should also be standard practice.

More contentious is the duration of use of low molecular weight heparin (LMWH). Some surgeons use a single dose immediately prior to the operation; we have used 5000 Units of Clexane post-operatively for 2-3 days. Orthopaedic surgeons are increasingly continuing LMWH for 28 days at home after joint replacement surgery, which carries a significant risk of VTE. Should we follow their lead? A simpler alternative from the patients’ viewpoint is daily use of one of the new oral anti-coagulants such as dabigatran.

Perhaps the most sensible approach clinically is to perform a risk assessment of all RALP candidates pre-operatively. A calf compression device and TED stockings should be used for all patients, together with LMWH, while in hospital. Those considered especially at risk with, for example, a BMI >30 (Becattini CA) (See Box 1), should usually go home for a month with either LMWH injections or daily oral dabigatran, or equivalent oral anticoagulant agent.

We would be most interested in the views, experiences and current practice of the readers of this piece. Please do post your own response.

 

Roger Kirby, Ben Challacombe and Prokar Dasgupta
The Prostate Centre, London W1G 8GT and Guy’s Hospital, King’s College London, King’s Health Partners

 

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Step-by-Step. Ergonomic use of the fourth arm

Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP)

Omer Karim, Amrith Rao, Emma Marsdin, Rajesh Kavia, Arie Parnham, Hanif Motiwala and Marc Laniado
Centre for Robotics and Minimally Invasive Surgery,Wexham Park Hospital, Slough, Berkshire, UK

Objective

• To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

Patients and Methods

• Balloon of a Foley catheter inflated in the bulbar urethra.
• Fourth arm cranial traction via suture in the tip of the catheter.
• DVC oversewn under direct vision.

Results

• Oversew of DVC with minimal patient-side surgical assistance.
• About a 50% reduction in apical positive margin rate.

Conclusion

• A useful, ergonomic method of oversewing the DVC
during RALP.

Karim O, Rao A, Marsdin E, et al. Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). BJU Int 2013; 111: 179–180.

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