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ABSTRACT Background and Objective Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. Materials and Methods We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. Conclusions Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.
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BACKGROUND AND OBJECTIVE: Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. MATERIALS AND METHODS: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. CONCLUSIONS: Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.
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Laparoscopia , Prostatectomia , Neoplasias da Próstata , Procedimentos Cirúrgicos Robóticos , Terapia de Salvação , Humanos , Prostatectomia/métodos , Prostatectomia/efeitos adversos , Masculino , Terapia de Salvação/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Laparoscopia/métodos , Recidiva Local de Neoplasia , Resultado do Tratamento , Complicações Pós-OperatóriasRESUMO
ABSTRACT Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID-19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID-19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID-19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.
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Pneumonia Viral/complicações , Procedimentos Cirúrgicos Urológicos/métodos , Urologia/normas , Urologia/tendências , Laparoscopia/métodos , Infecções por Coronavirus/complicações , Transmissão de Doença Infecciosa/prevenção & controle , Pandemias , Procedimentos Cirúrgicos Robóticos/métodos , Urologistas , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Pneumonia Viral/epidemiologia , Procedimentos Cirúrgicos Urológicos/tendências , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/epidemiologia , Fluxo de Trabalho , Procedimentos Cirúrgicos Robóticos/tendências , Betacoronavirus , SARS-CoV-2 , COVID-19RESUMO
Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.
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Infecções por Coronavirus/complicações , Transmissão de Doença Infecciosa/prevenção & controle , Laparoscopia/métodos , Pandemias , Pneumonia Viral/complicações , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Urologistas , Urologia , Betacoronavirus , COVID-19 , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Procedimentos Cirúrgicos Robóticos/tendências , SARS-CoV-2 , Procedimentos Cirúrgicos Urológicos/tendências , Urologia/normas , Urologia/tendências , Fluxo de TrabalhoAssuntos
Robótica , Ureter , Comorbidade , Humanos , Laparoscopia , Procedimentos Cirúrgicos UrológicosRESUMO
UNLABELLED: The surgical management of patients with symptomatic metastatic or locally advanced recurrences involving the penis remains poorly characterized. The aim of the present abstract and video is to detail our experience in the surgical management of a specific patient with a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate cancer treated with primary brachytherapy. MATERIALS AND METHODS: A 70 year old male patient initially treated for localized prostate cancer with interstitial brachytherapy at an outside facility developed an unfortunate secondary malignancy consisting of a locally advanced penile sarcoma involving as well the prostate and base of the bladder. Despite our best efforts to control his pain, he developed a very symptomatic local recurrence with a secondary penile abscess and purulent periurethral drainage. At this time, it was felt a surgical resection consisting of a total penectomy, urethrectomy, cystoprostatectomy, and ileal conduit urinary diversion would be the best option for local cancer control in this particular patient. RESULTS: The patient underwent the surgical resection without any complications as illustrated in this surgical video, with a jejunal intestinal mass identified at the time of surgery which was resected with a primary bowel anastomosis performed. The patient was discharged from hospital uneventfully with his symptomatic local recurrence being successfully managed and the patient no longer requiring oral narcotics for pain control. The pathological report confirmed a locally advanced sarcoma involving the penile, prostate, and bladder which was resected with negative surgical margins and the jejunal mass was confirmed to represent a small bowel sarcoma metastatic site. CONCLUSION: As highlighted in the present video, the treatment of a symptomatic sarcoma local recurrence contiguously involving the penis can be successfully managed provided the patient is informed of the potential morbidity and psychosocial implications imparted by performing a total penectomy and adjacent organ resection.
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Recidiva Local de Neoplasia/cirurgia , Segunda Neoplasia Primária/cirurgia , Neoplasias Penianas/cirurgia , Neoplasias da Próstata/radioterapia , Sarcoma/cirurgia , Idoso , Braquiterapia , Humanos , Masculino , Neoplasias Penianas/secundário , Sarcoma/secundário , Resultado do TratamentoRESUMO
Background The surgical management of patients with symptomatic metastatic or locally advanced recurrences involving the penis remains poorly characterized. The aim of the present abstract and video is to detail our experience in the surgical management of a specific patient with a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate cancer treated with primary brachytherapy. Materials and Methods A 70 year old male patient initially treated for localized prostate cancer with interstitial brachytherapy at an outside facility developed an unfortunate secondary malignancy consisting of a locally advanced penile sarcoma involving as well the prostate and base of the bladder. Despite our best efforts to control his pain, he developed a very symptomatic local recurrence with a secondary penile abscess and purulent periurethral drainage. At this time, it was felt a surgical resection consisting of a total penectomy, urethrectomy, cystoprostatectomy, and ileal conduit urinary diversion would be the best option for local cancer control in this particular patient. Results The patient underwent the surgical resection without any complications as illustrated in this surgical video, with a jejunal intestinal mass identified at the time of surgery which was resected with a primary bowel anastomosis performed. The patient was discharged from hospital uneventfully with his symptomatic local recurrence being successfully managed and the patient no longer requiring oral narcotics for pain control. The pathological report confirmed a locally advanced sarcoma involving the penile, prostate, and bladder which was resected with negative surgical margins and the jejunal mass was confirmed to represent a small bowel sarcoma metastatic site. Conclusion As highlighted in the present video, the treatment of a symptomatic sarcoma local recurrence contiguously involving the penis can be successfully managed provided the patient ...
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Idoso , Humanos , Masculino , Recidiva Local de Neoplasia/cirurgia , Segunda Neoplasia Primária/cirurgia , Neoplasias Penianas/cirurgia , Neoplasias da Próstata/radioterapia , Sarcoma/cirurgia , Braquiterapia , Neoplasias Penianas/secundário , Sarcoma/secundário , Resultado do TratamentoRESUMO
PURPOSE: To present the surgical technique of ventral phalloplasty as an adjunct procedure to the classic prosthetic surgery. MATERIALS AND METHODS: In this video we demonstrate how to perform a ventral phalloplasty in a patient that has undergone a penile prosthesis implantation. Our technique consists of: delineation of the penile scrotal web, excision of this redundant skin, and re-approximation of the wound to mimic the natural median raphe. RESULTS: The ventral phalloplasty improves the perception of phallic length, as well as patients' satisfaction after prosthetic surgery. CONCLUSION: Penile length perception is the main concern of patients that have undergone penile prosthesis implantation. In this video we demonstrate that the ventral phalloplasty can improve perception of phallic length, and can be an important adjunct to the classic prosthetic surgery.
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Implante Peniano/métodos , Prótese de Pênis , Pênis/cirurgia , Humanos , Masculino , Resultado do TratamentoAssuntos
Humanos , Masculino , Prótese de Pênis , Implante Peniano/métodos , Pênis/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: The management of a post-chemotherapy retroperitoneal mass secondary to testicular cancer can present a surgical challenge when involving adjacent organs or major vascular structures. We present the first video of a retroperitoneal lymph node dissection (RPLND) with IVC (inferior vena cava) thrombectomy, caval wall resection resulting from metastatic non-seminomatous germ cell testis (NSGCT) cancer. METHODS: In this surgical video, we highlight important surgical considerations in the management of a postchemotherapy retroperitoneal mass with direct IVC wall invasion and level 2 thrombus in such a patient. RESULTS: A 34 year old man underwent a right inguinal orchiectomy for a mixed NSGCT (embryonal, yolk sac, and teratoma components) and elevated serum tumor markers. He underwent systemic chemotherapy (BEP regimen x 4 cycles) with subsequent near normalization of tumor markers. His post-chemotherapy imaging revealed a 6 cm residual retroperitoneal mass with a level 2 IVC tumor thrombus and suspected direct infrarenal IVC wall invasion from the mass. The patient underwent an open post-chemotherapy RPLND, IVC thrombectomy, IVC resection and grafting. The final pathology report of the retroperitoneal mass revealed teratoma with no viable germ cell tumor elements and negative surgical margins. His intra-operative and post-operative stages were unremarkable with his IVC graft remaining patent and no evidence of disease recurrence at last follow-up. CONCLUSION: We present the first surgical video of a post-chemotherapy RPLND with IVC thrombectomy, caval wall resection and grafting for metastatic NSGCT. The final pathology report of teratoma with no viable tumor highlights the local vascular invasive potential of such pathology.
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Excisão de Linfonodo/métodos , Neoplasias Retroperitoneais/secundário , Teratoma/secundário , Neoplasias Testiculares/patologia , Trombectomia/métodos , Veia Cava Inferior/cirurgia , Adulto , Humanos , Masculino , Neoplasias Retroperitoneais/cirurgia , Espaço Retroperitoneal , Teratoma/cirurgia , Tomografia Computadorizada por Raios XAssuntos
Adulto , Humanos , Masculino , Excisão de Linfonodo/métodos , Neoplasias Retroperitoneais/secundário , Teratoma/secundário , Neoplasias Testiculares/patologia , Trombectomia/métodos , Veia Cava Inferior/cirurgia , Espaço Retroperitoneal , Neoplasias Retroperitoneais/cirurgia , Tomografia Computadorizada por Raios X , Teratoma/cirurgiaRESUMO
PURPOSE: Various treatment options are available for small incidentally detected kidney masses, including surveillance, partial nephrectomy and probe ablative therapies. When partial nephrectomy is considered, the procedure can be safely approached laparoscopically, either pure or robot assisted, in experienced hands. Laparo-endoscopic single site (LESS) surgery is a novel approach for partial nephrectomies in well selected cases. In this video, we present our experience with the LESS retroperitoneal partial nephrectomy using the Gelpoint device. MATERIAL AND METHODS: A 63 year old male patient with a BMI of 31, and a history of a T1c prostate cancer, had a 1.5 cm right posterior lower pole renal enhancing mass discovered incidentally on a three phase CT scan. With the patient under general anesthesia, and in a full flank position, a LESS retroperitoneal partial nephrectomy was performed using a 3 cm transverse incision below the tip of the 12th rib. The following instruments and devices were used: A gelpoint device for single incision port of entry, one 10 mm and two 5 mm trocars used through the gelpoint, one 5 mm Olympus HD endoeye flexible tip camera, one roticulator scissors, and one articulating graspers. RESULTS: Operative time, EBL, and hospital stay were 1 hour, 5 ml, and 23 hours, respectively. The pathology result confirmed a benign hemorrhagic cystic mass. The visual analog scale (0-10) for pain at recovery, 6 hours post op, and 23 hours post op was 5, 3, and 1 point, respectively. The patient tolerated clear liquids and regular diet at 6 and 16 hours, after the procedure. At one month of follow-up, the patient is asymptomatic and practically scarless. CONCLUSIONS: LESS retroperitoneal partial nephrectomy is safe and feasible in selected cases such as small exophytic posterior renal masses. The retroperitoneal approach avoids mobilization of the colon and kidney to access the posterior surface. Instrument clashing, limited range of motion, and CO2 leakage, can be some difficulties encountered during single port retroperitoneal surgery. However, the Gelpoint device gives a great seal in the flank position and allows the relocation of trocars, without loss of CO2 pressure, to prevent instrument clashing during different parts of the procedure.
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Laparoscopia/métodos , Nefrectomia/métodos , Idoso , Humanos , Laparoscopia/instrumentação , Masculino , Nefrectomia/instrumentação , Neoplasias da Próstata/cirurgia , Espaço Retroperitoneal , Resultado do TratamentoRESUMO
PURPOSE: Gonadal vein syndrome, with ureteral obstruction and compression by an overlying testicular vein is a controversial and rare diagnosis. Open, laparoscopic, and robot-assisted laparoscopic repairs have been described. We report the first case of robot-assisted gonadal vein ligation for treatment of gonadal vein syndrome in a nine year-old boy. MATERIALS AND METHODS: A 9 years-old boy presented with a four to six month history of worsening intermittent flank pain, nausea and vomiting. Ultrasound revealed moderate hydronephrosis. Diuretic renography and intravenous pyelography reproduced his pain and demonstrated left-sided hydronephrosis and obstruction. The patient underwent left robot-assisted surgery via a four port approach. The colon was reflected medially. The gonadal vein was dissected off the underlying ureter and ligated using laparoscopic clips. Segmental vein excision and ureterolysis was performed. Inspection of the renal hilum did not reveal any other crossing vessels. RESULTS: Operative time was 94 minutes. The patient was discharged 36 hours after surgery. His hydronephrosis has resolved completely. He remains pain-free nine months after surgery. CONCLUSION: Robot-assisted laparoscopic vein excision and ureterolysis is a safe option for the management of ureteral obstruction caused by the gonadal vein.
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Hidronefrose/cirurgia , Laparoscopia/métodos , Veias Renais/cirurgia , Cirurgia Assistida por Computador/métodos , Obstrução Ureteral/cirurgia , Criança , Humanos , Hidronefrose/etiologia , Masculino , Veias Renais/anormalidades , Robótica , Resultado do Tratamento , Obstrução Ureteral/etiologiaAssuntos
Criança , Humanos , Masculino , Hidronefrose/cirurgia , Laparoscopia/métodos , Veias Renais/cirurgia , Cirurgia Assistida por Computador/métodos , Obstrução Ureteral/cirurgia , Hidronefrose/etiologia , Robótica , Veias Renais/anormalidades , Resultado do Tratamento , Obstrução Ureteral/etiologiaRESUMO
PURPOSE: The management of penile cancer has evolved as less invasive techniques are applied in the treatment of the primary tumor and inguinal lymph nodes. MATERIALS AND METHODS: Herein we review the literature focusing on advances in the preservation of the phallus as well as less morbid procedures to evaluate and treat the groins. RESULTS: Promising imaging modalities for staging are discussed. New techniques are described and tables provided for penile preservation. We also review the contemporary morbidity of modified surgical forms for evaluation of the inguinal nodes. CONCLUSIONS: Advances in surgical technique have made phallic preservation possible in a greater number of primary penile cancers. The groins can be evaluated for metastasis with greater accuracy through new radiologic means as well as with less morbid modified surgical techniques.
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Neoplasias Penianas/cirurgia , Virilha , Humanos , Excisão de Linfonodo/métodos , Metástase Linfática/diagnóstico , Masculino , Estadiamento de Neoplasias , Neoplasias Penianas/patologiaRESUMO
Purpose: The management of penile cancer has evolved as less invasive techniques are applied in the treatment of the primary tumor and inguinal lymph nodes. Materials and Methods: Herein we review the literature focusing on advances in the preservation of the phallus as well as less morbid procedures to evaluate and treat the groins. Results: Promising imaging modalities for staging are discussed. New techniques are described and tables provided for penile preservation. We also review the contemporary morbidity of modified surgical forms for evaluation of the inguinal nodes. Conclusions: Advances in surgical technique have made phallic preservation possible in a greater number of primary penile cancers. The groins can be evaluated for metastasis with greater accuracy through new radiologic means as well as with less morbid modified surgical techniques.