Technical modifications for robot-assisted laparoscopic pyeloplasty

PURPOSE: Laparoscopic pyeloplasty (LP) is gaining acceptance as a standard of care for the repair of ureteropelvic junction (UPJ) obstruction, with results comparable to those of open repair. However, it remains a technically challenging procedure requiring intracorporeal suturing skills. Recent reports have demonstrated equally effective results with robot-assisted laparoscopy with shorter operative times. We present our modified technique for daVinci robot-assisted LP. PATIENTS AND METHODS: From November 2002 to May 2004, 32 consecutive patients underwent LP with the daVinci robotic system for UPJ obstruction. Just prior to laparoscopy, 31 patients underwent retrograde pyelography and cystoscopic placement of a ureteral catheter just distal to the UPJ, which was prepared into the operative field. The remaining patient had an indwelling stent placed preoperatively. Three transperitoneal ports are placed for the robot. A fourth port is placed for retraction, suction, dissection, and suture passage by the bedside surgeon. This port was placed at McBurney's point in the first two patients and the subxiphoid area in the subsequent 30 patients. A ureteral stent was inserted retrograde intraoperatively with laparoscopic assistance after exchanging the ureteral catheter for a guidewire. A Jackson-Pratt drain was placed in all cases. RESULTS: All procedures were completed laparoscopically. Anderson-Hynes dismembered pyeloplasty was performed in 31 patients, while Fengerplasty was performed in 1 patient. The average operative time was 300 minutes (initial 12 procedures: 384 minutes; last 10 procedures: 197 minutes). The average blood loss was approximately 50 mL and the average hospital stay 1.1 days. A crossing vessel was present in 44% of the cases. Stone extraction was performed in 5 cases (23%) and kidney biopsy in 1 case. The only perioperative complications were one migrated stent, which was repositioned under sedation without sequelae and one urinary tract infection. Of the 18 patients with follow-up exceeding 6 months (average 10.3 months), 16 have improved drainage and function and are asymptomatic. One patient with flank pain has no evidence of obstruction. One with delayed, although improved, drainage is asymptomatic. CONCLUSIONS: The daVinci robot system can be used effectively for LP. Although initial operative times were long, there was a significant decrease after the first 12 cases. Having retrograde access to the ureter allows simple intraoperative stent placement. We found that the subxiphoid placement of the fourth port gave the bedside surgeon the optimal location for suction, dissection, and intracorporeal suture passage. This approach and technique have become standard in our treatment of UPJ obstruction.     

Accuracy and precision of MR velocity mapping in measurement of stenotic cross-sectional area,flow rate,and pressure gradient

Reliability of magnetic resonance (MR) velocity mapping to assess severity of stenosis was assessed in vitro. Steady flow at different flow rates through five stenoses with a central orifice area ranging from 17 to 176 mm² was measured with velocity mapping performed perpendicular to the stenotic jet. Besides determination of the stenotic cross-sectional area and flow rate, the pressure gradient was calculated with the modified Bernoulli equation and compared with manometer measurements. Cross-sectional areas were measured with an accuracy of ?76%, a precision of ?91%, and an error of ?19 mm². Flow rates had an accuracy of ?72%, a precision of ?94%, and an error of ?1.4 L/min. The modification of the Bernoulli equation limited its reliability to stenoses with areas of 35-113 mm². Pressure gradients were calculated with an accuracy of ?80%, a precision of ?88%, and an error of ?15 mm Hg. The method was applied in a single patient with aortic stenosis and gave estimates that agreed with those obtained by heart catheterization.     

Limitations of peritoneal lavage with antiseptics in prevention of recurrent colorectal cancer caused by tumor-cell seeding

PURPOSE: Exfoliated or soiled free malignant cells have serious consequences in patients undergoing gastrointestinal cancer surgery. The present study evaluates the toxicity and efficacy of cytotoxic agents in the prevention of cell seeding and tumor growth in the peritoneal cavity in an experimental model. METHODS: Mtln3 adenocarcinoma cell viability was testedin vitro using the trypan blue exclusion test after incubation with povidone-iodine or chlorhexidine.In vivo, Fischer rats were inoculated with 10⁵ or 10⁶ cells followed by peritoneal lavage with physiological saline, chlorhexidine 0.02 percent, providone-iodine low molecular weight 1 percent or povidone-iodine high molecular weight 1 and 2 percent in different quantities and incubation times. RESULTS: Chlorhexidine 0.02 percent and povidone-iodine low molecular weight 1 percent or high molecular weight 2 percent, killed over 98 percent of 10⁵ or 10⁶ tumor cellsin vitro. Povidone-iodine low molecular weight 1 percent and high molecular weight 2 percent were toxic and lethal when 5 ml were applied in the peritoneal cavity three times for five minutes. Chlorhexidine 0.02 percent applied after inoculation of 10⁵ or 10⁶ cells, reduced the tumor development only to 70 and 80 percent. Application of 5 ml povidone-iodine 1 percent low molecular weightor high molecular weight, three times for one and five minutes, after inoculation of 10⁶ cells did not change the tumor take. However, inhibition of Mtln3 cells to form metastases was observed. When povidone-iodine low molecular weight 1 percent was used three times for one minute after 10⁵ tumor cells were soiled, no toxicity was observed and the tumor take was reduced to 30 percent (P<0.05). CONCLUSIONS: Povidone-iodine toxicity proved to be a major issuein vivo. However, povidone-iodine low molecular weight 1 percent was safe when used for short periods and very effective when a limited number of tumor cells was inoculated. The use of cytotoxic agents to prevent recurrent disease caused by tumor cell seeding in patients seems to make sense only when the inoculum size of exfoliated or soiled cancer cells is limited.     

Enhanced Recovery After Surgery (ERAS) Protocol: Prospective Study of Outcome in Colorectal Surgery

Background : Fast-track programs (ERAS) have been shown to improve postoperative recovery in colorectal surgery, combining newer anesthetic and minimally invasive surgery with evidence-based adjustments to facilitate revalidation. This prospective study evaluated the outcome of an ERAS protocol implementation in a university colorectal unit.

Methods : Between 2009 and 2010, 94 patients (49 males and 45 females) underwent an elective colorectal resection and were included in this protocol. All data were prospectively gathered in an electronic database. A cohort comparison was performed with 120 patients operated on in 2008 before ERAS implementation.

Results : The median age was 58 years [range: 29–76 years] and the median ASA score was 2. All colorectal procedures (85 sigmoid resections, 7 right hemicolectomies and 2 low anterior resections) were performed laparoscopically, with a conversion rate of 9,5%. Complications were noted in 14 patients (14,9%); two patients (2,1%) required a laparoscopic drainage of an infected hematoma during initial hospital stay. A significant (p < 0,001) reduced median postoperative hospital stay of 4 days [range: 2–11 days] in the ERAS group, compared with 6 days [range: 3–37] in the non fast-track group was noted. Early readmission occurred in five patients (5,3%) because of anastomotic leakage (n = 2), ileus (n = 2) and a wound infection (n = 1).

Conclusion : These results of length of stay, morbidity and readmission-rates have important implications for the organization of health care, waiting lists and costs. Therefore the ERAS principles should be more wide-spread implemented.     

Recurrent Symptoms after Stapled Haemorrhoidopexy and the Impact on Patient Satisfaction after a Minimum of 2 Years Follow-up

Background : Stapled haemorrhoidopexy came as an attractive alternative to treat grade 3 haemorrhoids. This study aims to assess the nature of recurrent symptoms and the impact on patient satisfaction after a minimum follow-up of two years in a group of patients who underwent stapled haemorrhoidopexy.

Methods : A standardized questionnaire was used to evaluate a consecutive group of patients by telephone treated by a stapled haemorrhoidopexy between January 2004 and December 2007. Outcome assessment comprised residual symptoms, subsequent treatment, and patient satisfaction.

Results : Hundred sixty-five patients underwent a stapled haemorrhoidopexy in the study period. Twenty-five patients (15%) were lost to follow-up. The included 140 patients presented with grade 2 (16) or grade 3 (124) prolapsing internal haemorrhoids. Median age was 50 years (range 27–79) and 56% were males. Median follow-up was 43 months (range 25–87). At final follow-up, 79 patients (56%) remained symptom-free. Nevertheless, 89% were more than satisfied. Only 11% were disappointed with the ultimate outcome. Recurrent symptoms were prolapse (52 patients), anal bleeding (46 patients), anal pressure or pain (24 patients) and pruritus (21 patients). Thirty-five patients had subsequent therapy: 20 underwent surgical resection and 15 had sclerotherapy or rubber band ligation. Patient satisfaction correlates with the number of recurrent (residual) symptoms and the need for further treatment.

Conclusion : Despite the high symptomatic recurrence rate after stapled haemorrhoidopexy, 89% of patients were satisfied. This suggests that recurrent or residual symptoms after stapled haemorrhoidopexy are often less severe compared to the initial presenting symptoms.