Technical refinement and learning curve for attenuating neurapraxia during robotic-assisted radical prostatectomy to improve sexual function

Background

While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes.

Objective

Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP).

Design, setting, and participants

We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction.

Surgical procedure

Our approach to RARP has been described previously. A single-console robotic system was used for all cases.

Outcome measurements and statistical analysis

Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function.

Results and limitations

Greater surgeon experience was associated with better 5-mo sexual function (p = 0.007) and a trend for better 12-mo sexual function (p = 0.061), with improvement plateauing after 250–300 cases. Additionally, younger patient age (both p < 0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p = 0.021), while unilateral nerve sparing/non–nerve sparing was associated with worse 5-mo sexual function (p = 0.009). Limitations include the retrospective single-surgeon design.

Conclusions

With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement.     

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare,but can comprise a great variety of histological types.Congenital tumors are the most common.Once the diagnosis is established,surgical resection is essential because of the potential for malignancy or infection.Previous biopsy is not necessary or may be even harmful.To decide the best surgical approach(abdominal,sacral or combined) an individual and multidisciplinary analysis must be carried out.We report three cases of cystic presacral masses in which a posterior approach(Kraske procedure) enabled complete resection,the only way to decrease local recurrence.All patients had a satisfactory recovery.A brief overview of retrorectal tumors is presented,focusing on classification,clinical presentation,diagnosis and surgical management.     

More than just stones: a pictorial review of common and less common gallbladder pathologies

Although stone disease is by far the most commonly encountered pathology of the gallbladder, there are several other important disease processes affecting it. These include adenomyomatosis, cholesterolosis, polyps, porcelain gallbladder, acalculous cholecystitis, xanthogranulomatous cholecystitis, emphysematous cholecystitis, gallbladder cancer, and gallbladder hemorrhage. The purpose of this article was to review the different gallbladder pathologies encountered in everyday radiological practice and to describe their features in the standard imaging modalities.     

Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder

We prospectively studied extracorporeal shock wave therapy (ESWT) for calcific tendinitis of the shoulder in 46 consecutive patients. All patients were randomly divided into 2 groups: treatment and control. The 33 patients in the treatment group received 2 courses of ESWT at the energy density of 0.55 mJ/mm(2) (1000 impulses). The control group underwent sham treatment with a dummy electrode (13 patients). Evaluation included the Constant score, pain scale, and radiographs. The ESWT results were good to excellent in 87.9% of shoulders (29/33) and fair in 12.1% (4/33), and the control results were fair in 69.2% (9/13) and poor in 30.1% (4/13). Among ESWT patients, calcium deposits were completely eliminated in 7 cases (21.2%), partially eliminated in 11 (36.3%), and unchanged in 15 (45.4%). In contrast, elimination was partial in 2 control patients (15.3%) and unchanged in 11 (84.7%). There was no significant difference between G?rtner type I and type II groups in the Constant score (P > .05). ESWT shows promise for pain relief and functional restoration of calcific tendinitis with negligible complications.     

Incidence and risk factors of development of lung tumors after liver transplantation

INTRODUCTION: Lung tumors have been related to tobacco and alcohol. The incidence increases after orthotopic liver transplantation (OLT) especially when it is performed because of alcoholic cirrhosis. PATIENTS AND METHODS: We analyzed the incidence and risk factors for de novo lung tumors among 701 patients who underwent OLT between April 1986 and July 2004, after exclusion of pediatric recipients and adults who died within 2 months after OLT. RESULTS: The incidence of de novo lung tumors was 15 patients (2.1%), including 12 (4.3%) who underwent OLT for alcoholic cirrhosis and 3 (0.7%) for nonalcoholic diseases. There were 14 men and 1 woman of mean age at OLT of 50.8 +/- 9.6 years. Mean time from OLT to lung tumor was 83 +/- 43 months (range, 10-184 months). Thirteen patients (86.6%) were heavy smokers before OLT and 8 (61.5%) continued after OLT; 12 patients (80%) were heavy drinkers before OLT. Ten patients were immunosuppressed with CyA and 5 with tacrolimus. Acute rejection episodes before tumor diagnosis occurred in 6 patients (40%). Two patients underwent thoracotomy, but only one was resected. The remaining 13 patients were unresectable because of locally advanced tumor or metastatic disease. Two unresectable patients received palliative chemotherapy. All patients died with a mean survival from tumor diagnosis, of 5.3 months (range, 3 days to 33 months). CONCLUSION: A significantly higher incidence of lung tumors was observed among patients who underwent OLT for alcoholic cirrhosis, usually diagnosed in advanced stages of poor prognosis and low survival.     

Hipogonadismo prolongado tras la suspensión de tratamiento hormonal en pacientes con cáncer de próstata

ObjectivesTo study the levels of LH, testosterone and PSA after suspending prolonged treatment with LH-RH analogs.Materials and MethodHormonal evolution was studied in 29 patients from whom treatment had been withdrawn. The patients had previously been receiving treatment with LH-RH analog for more than one year, and with LH< 2 mUI/mL and testosterone <2.8 ng/mL. LH, testosterone and PSA were determined monthly, together with clinical assessment. The treatment was re-initiated and the period of monitoring ended before the presence of clinical progression and/or PSA ? 10 ng/mL. The cohort was described and survival was calculated using Kaplan-Meier and Cox regression.ResultsThe mean period of time without treatment for the series was 35 months (CI 95%, 15.7-54.2 months). Prolonged hypogonadism (> 24 months) was presented by 17% of the patients. The recovery of the LH-T-PSA axis, when it occurred, followed the expected sequence. The variables that influenced the period of recovery of the PSA were the PSA pretreatment and the association of an antiandrogen.ConclusionsAfter withdrawing the prolonged treatment with LH-RH analogs, most of the patients recovered the levels of LH-T-PSA, although a subgroup remained hypogonadic for more than 24 months.