Surgical Outcomes of Transperitoneal Para-Aortic Lymphadenectomy Compared With Extraperitoneal Approach in Gynecologic Cancers: A Systematic Review and Meta-Analysis

Purpose: The optimal surgical approach for para-aortic lymphadenectomy (PALND) in gynecologic cancers using minimally invasive surgery (laparoscopy or robotic-assisted) is controversial. This study summarizes the current evidence on the extraperitoneal (EP) approach and compares its perioperative, surgical outcomes, and complications to the transperitoneal (TP) approach in an updated meta-analysis.Methods: We performed a systematic search in PubMed, Embase, Web of Science, Cochrane Library database for randomized controlled trials (RCTs) and non-RCTs that compare EP to TP for PALND. The main outcomes included surgical, perioperative outcomes, and complications. The weighted mean difference (WMD) and odds ratio (OR) were applied for the comparison of continuous and dichotomous variables with 95% CIs. Three RCTs and 10 non-RCTs trials, including 2,354 patients were identified and enrolled in the meta-analysis.Results: A total of three RCTs and ten non-RCTs trials, including 2,354 patients were identified and enrolled in the meta-analysis. We reported similar results for EP and TP in terms of the hospital stay, estimated blood loss, blood transfusion, conversion to laparotomy, total operative time, and postoperative complications (Clavien grade ≥ 1 and Clavien grade ≥ 3). However, the PALND operative time (WMD −10.46 min, 95% CI −19.04, −1.88; p = 0.02) and intraoperative complications (OR 0.40, 95% CI 0.23, 0.69; p = 0.001) were less with EP. Also, more nodes were removed in EP compared with the TP (WMD 1.45, 95% CI 0.05, 2.86; p = 0.04).Conclusions: The EP approach did not show differences regarding surgical and perioperative parameters compared with the TP approach. However, the number of aortic nodes retrieved was higher. Furthermore, The PALND operative time and intraoperative complications were less in EP.

Laparoscopic donor nephrectomy: technique and outcome, a single-center experience

Background Laparoscopic donor nephrectomy (LDN) has been established as a surgical standard for living kidney donation. The aim of this work is to report our own experience with LDN regarding outcome and technique. Methods We prospectively identified 110 LDN cases between May 2017 and April 2020. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time (WIT), intraoperative and postoperative complications, operative time, and length of hospital stay (LOS). Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, the USA). Results The mean age was 38 years, and 77% were males. Three cases (2.72%) required conversion to conventional open donor nephrectomy (ODN). Nevertheless, none of cases required intraoperative blood transfusion. The mean WIT was 2.6 min. Two cases (1.8%) developed major vascular injury (Clavien grade IIIb) and required conversion to ODN. Postoperatively, one patient (0.9%) needed transfusion of one unit of packed RBCs (Clavien grade II). The mean LOS was 2 days. Most common early postoperative complication was ileus (Clavien grade II) that developed in 4 (3.6%) cases. Incisional hernia (Clavien grade IIIb) was encountered in two (1.8%) cases. Two (1.8%) cases developed wound infection at the incision site and treated conservatively (Clavien grade I). Conclusions LDN is a safe technique with accepted intraoperative and postoperative morbidity. It offers short hospital stay, better cosmesis and early convalescence. In experienced hands, it can effectively deal with various vascular and ureteral anomalies without compromising early graft function.

Romanian National premiere with the new Thulium SuperPulsed Laser in the endourological treatment of urolithiasis

In this paper, we aimed to verify the efficiency and functionality of the new Soltive Thulium Fiber Laser (TFL) in the treatment of urinary stones. The Soltive Laser System was used in 17 urolithiasis cases: 10 renal, 5 ureteral, and 2 bladder stone patients. The average stone size was 13.1 mm (ranging between 11–29 mm) for the kidney, 8 mm (ranging between 6–12 mm) for the ureter, and 31 mm (ranging between 27–34 mm) for the bladder. Only single calculi patients were included in the study. We used 100 and 150 μm core-diameters fibers (CDF). Three settings were applied: 0.15 J/100 Hz for “fine dusting”, 0.5 J/30 Hz for “dusting” and 1 J/15 Hz for the fragmentation mode. The mean operative time was 34 minutes for renal, 21 minutes for ureteral, and 39 minutes for bladder stones. The visibility was optimal in all cases. The stone-free rate at 1 month after treatment was 95% for renal calculi and 100% for ureteral and bladder stones. Very fine dust made of stone fragments smaller than 1 mm in size that passed spontaneously through the access sheath was observed, especially subsequent to the “fine dusting” mode. The complication rate was very low: 1 patient was classified as Clavien grade 1 and 1 patient as Clavien grade 2, and this was the case for renal stones only. No urinary tract infections were observed. The new Soltive TFL appears to be a remarkably promising tool in the therapeutic approach of urolithiasis. Lithotripsy was achieved up to the level of extremely small stone fragments with improved efficiency while also optimizing the operative time.

Pediatric endoscopic pilonidal sinus treatment (PEPSiT): what we learned after a 3-year experience in the pediatric population

This paper aimed to report a multi-institutional 3-year experience with pediatric endoscopic pilonidal sinus treatment (PEPSiT) and describe tips and tricks of the technique. We retrospectively reviewed all patients < 18 years, with primary or recurrent pilonidal sinus disease (PSD), undergoing PEPSiT in the period 2017–2020. All patients received pre-operative laser therapy, PEPSiT and post-operative dressing and laser therapy. Success rate, healing rate/time, post-operative management, short- and long-term outcome and patient satisfaction were assessed. A total of 152 patients (98 boys) were included. Median patient’s age was 17.1 years. Fifteen/152 patients (9.8%) presented a recurrent PSD. All patients resumed full daily activities 1 day after surgery. The post-operative course was painless in 100% of patients (median VAS pain score < 2/10). Patient satisfaction was excellent (median score 4.8). The median follow-up was 12.8 months (range 1–36). Complete healing in 8 weeks was achieved in 145/152 (95.4%) and the median healing time was 24.6 days (range 16–31). We reported post-operatively immediate Clavien grade 2 complications (3 oedema, 2 burns) in 5/152 (3.3%) and delayed Clavien grade 2 complications (3 granulomas, 8 wound infections) in 11/152 (7.2%). Disease recurrence occurred in 7/152 (4.6%), who were re-operated using PEPSiT. PEPSiT should be considered the standard of care for surgical treatment of PSD in children and teenagers. PEPSiT is technically easy, with short and painless post-operative course and low recurrence rate (4.6%). Standardized treatment protocol, correct patient enrollment and information, and intensive follow-up are key points for the success of the procedure.

MR-Guided Microwave Ablation in T1 Renal Cell Carcinoma: Initial Results in Clinical Routine

Objective. Percutaneous tumor ablation is usually performed using computed tomography (CT) or ultrasound (US) guidance, although reliable visualization of the target tumor could be challenging. Magnetic resonance- (MR-) guided ablation provides more reliable visualization of the target tumors and allows multiplanar imaging of the treatment process, making it the modality of choice, in particular if lesions are small. Methods. From March 2016 to January 2018, 32 patients scheduled for percutaneous treatment of T1 RCC underwent MR-guided MWA. Complications were classified according to the Clavien grade. Kaplan–Meier survival estimates were calculated to evaluate progression-free survival (PFS). Results. Technical success was achieved in all lesions. The mean energy and procedure duration were 61.6 ± 8.7 kJ and 118.2 ± 26.7 min, respectively. The glomerular filtration rate (GFR) dropped rapidly after 1 month of treatment and slowly recovered within three months ( P < 0.05 ). Postoperative pain and fever were the most common adverse events after treatment. Perirenal hematoma, thermal injury of the psoas muscle, and abdominal distension were common complications after MWA, and the incidence rates were 9.4% (3/32), 6.3% (2/32), and 6.3% (2/32), respectively. According to the Clavien grade classification, serious complications include hydrothorax, bowel injury, and renal failure, all of which have a probability of 3.1%. Of note, the three serious complications occurred in one patient. The 1-, 2-, and 3-year PFS rates were 96.9%, 93.8%, and 83.9%, respectively. The mean PFS rates were 33.972 months (95% CI: 33.045, 35.900). Conclusion. Microwave ablation is feasible under MR guidance and provides effective treatment of RCC in one session.

Transhepatic hilar approach for Bismuth types III and IV perihilar cholangiocarcinoma with long-term outcomes

Objective To compare the outcomes of the transhepatic hilar approach and conventional approach for surgical treatment of Bismuth types III and IV perihilar cholangiocarcinoma. Methods We retrospectively reviewed the medical records of 82 patients who underwent surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma from 2008 to 2016. The transhepatic hilar approach and conventional approach was used in 36 (43.9%) and 46 (56.1%) patients, respectively. Postoperative complications and overall survival were compared between the two approaches. Results Similar clinical features were observed between the patients treated by the conventional approach and those treated by the transhepatic hilar approach. The transhepatic hilar approach was associated with less intraoperative bleeding and a lower percentage of Clavien grade 0 to II complications than the conventional approach. However, the transhepatic hilar approach was associated with a higher R0 resection rate and better overall survival. Multivariate analysis showed that using the transhepatic hilar approach, the Memorial Sloan-Kettering Cancer Center classification, and R0 resection were independent risk factors for patient survival. Conclusion The transhepatic hilar approach might be the better choice for surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma because it is associated with lower mortality and improved survival.

Factors that predict urinary retention in patients who underwent inguinal hernia repair

Background: Some of the patients that undergo inguinal hernia repair develop urinary retention. We aimed to determine the rate of development of urinary retention and predicting factors after inguinal hernia repair.Methods: Patients who underwent inguinal hernia in our center from January 2017 to January 2020 were included in the study. Patients were examined in 2 groups; group1 (developed urinary retention after inguinal hernia repair) and group 2 (did not develop urinary retention after inguinal hernia repair). We investigated the relationship between the development of urinary retention with age, perioperative history of benign prostate obtruction, hernia type and localization, duration of surgery and anesthesia, perioperative non-steroidal anti-inflammatory drug (NSAID), narcotic analgesic and antispasmolytic use, having diabetus mellitus (DM) and rheumatoid diseases, and perioperative fluid replacement.Results: in group 1 and group 2, urinary retention developed in 11 (7.6%) of the patients. Patients who developed post-urinary retention were older than those without urinary retention (p=0.007). The BPO, DM rates were higher (p=0.0001), anesthesia and operation times were longer (p=0.003; p=0.0001); perioperative antispasmolytic use was higher (p=0.0001); we determined that postoperative fluid replacement rate was higher (p=0.003) and the rate of preoperative NSAID use was lower (p=0.0001). Clavien grade 4 and grade 5 complications were not observed in patients.Conclusions: Elderliness, DM history, antispasmolytic use, long operation and anesthesia duration, excessive postoperative fluid replacement and, not using perioperative NSAID increases the risk of urinary retention.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation

Introduction: Robotic pediatric urologic surgery has gained widespread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR). Methods: We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student’s t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system. Results: A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort. Conclusions: Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP and especially RUR warrant further study to ensure lack of significant complications noted in our study.

Effectiveness of the self-retrieval basketing technique for stone extraction during flexible ureteroscopy for urolithiasis

Background To assess the safety and effectiveness of using the self-retrieval basketing technique by solo surgeon as a method for stone extraction during flexible ureteroscopy (f-URS) for urolithiasis. Methods This retrospective study enrolled patients with urinary calculus who underwent f-URS at two institutions in Japan between September 2014 and November 2019. A total of 100 cases were performed by one experienced surgeon using the self-retrieval basketing technique. With this approach, the f-URS apparatus was manipulated with the nondominant hand and the basket catheter was manipulated with the dominant hand. The self-retrieval basketing technique employed two parts—specifically, a “front catch” and “side catch” to gather fragmented stones visible in the front and side of the ureteroscopic view, respectively. We retrospectively examined perioperative results, complications, and the stone free rate (with “stone-free” defined as ≤ 2 mm with kidney ureter bladder (KUB) 1 month after f-URS) to estimate the safety and effectiveness for comparison with results of the conventional retrieval basketing technique. Results Among our study population, the median stone size was 14 mm and the median operative time was 80 minutes. A stone free status was achieved in 87 patients (87%). The median stone fragmentation time was 16 minutes and the stone retrieval time was 32 minutes. All included cases were completed with the self-retrieval basketing technique. Complications related to stone retrieval were identified in two cases (2%); the degree of ureter injury being Clavien grade IIIa. There were no intraoperative complications such as heavy hematuria not to detect ureteral mucosa. Conclusions The self-retrieval basketing technique is safe and effective for the extraction of stone fragments during f-URS for urolithiasis. The self-retrieval basketing technique does not require assistance for basketing; therefore, f-URS with active retrieval basketing could be completed by solo surgeon.

Central segments liver resection for pediatric tumors

Aim. To analyze the short-term outcomes of сentral segments liver resection in children, according to the initial experience.Мethods. The data of patients with different centrally located liver neoplasms were analyzed. This retrospective study included three patients with hepatoblastoma, one observation of mesenchymal hamartoma of the liver and one patient with hepatocellular carcinoma. Different types of central liver resections were carried out in these patients between March and October 2018. The technical aspects and the short-term results are described.Results. Median age of patients was 78 months (9 months – 12 years). Patients underwent: segmentectomy 4b, bisegmentectomy 4b, 5, threesegmentectomy 4, 5, 6, mesohepatectomy (anatomical segmentectomy 4, 5, 8) with biliary reconstruction for posterior liver segments, mesohepatectomy with anatomical segmentectomy 6 and atypical S2, 3 resection. Dindo–Clavien grade IIIa postoperative complication developed in one patient. Vascular complications and posthepatectomy liver failure were absent. The hospital stay ranged between 9 to 14 days. The median follow-up period came to 8 months (7–14 months). The overall and event free survival at the time of writing is 100%.Conclusion. Resections of central liver segments in children are feasible and should be carried out in experiences in liver surgery centers.