Re: A Prospective Randomized Study of Pfannenstiel versus Expanded Port Site Incision for Intact Specimen Extraction in Laparoscopic Radical Nephrectomy

Abstract

available at http://www.ncbi.nlm.nih.gov/pubmed/25819645 Editorial Comment: In this study the authors randomized 51 laparoscopic transperitoneal radical nephrectomy cases with intact specimen extraction to either Pfannenstiel or expanded port site incision. Pain scores on postoperative day 1 and hospital stay were significantly less for the Pfannenstiel group, although clinically the improvements were modest (less than 1 point on Likert pain scale and half day hospital stay). Extensive cosmesis and operative satisfaction questioning demonstrated no difference between the groups. Surprisingly the “extra” Pfannenstiel incision did not increase operative time or extraction time, which I believe has been the main impediment to widespread use of the Pfannenstiel extraction. I certainly will use this incision more often for specimen retrieval. Jeffrey A. Cadeddu, MD Re: Minimally Invasive Percutaneous Treatment of Small Renal Tumors with Irreversible Electroporation: A Single-Center Experience C. K. Trimmer, A. Khosla, M. Morgan, S. L. Stephenson, A. Ozayar and J. A. Cadeddu Departments of Radiology and Urology, University of Texas Southwestern Medical Center, Dallas, Texas J Vasc Interv Radiol 2015; 26: 1465e1471. doi: 10.1016/j.jvir.2015.06.028 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26250855available at http://www.ncbi.nlm.nih.gov/pubmed/26250855 902 BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY Editorial Comment: Irreversible electroporation (IRE) is a new ablation method that uses highvoltage pulses to create permanent nanopores in cells, resulting in cell membrane destabilization and death. IRE is commonly used clinically in liver and pancreas tumor ablation. Since it is purported to be nonthermal, this approach may provide advantages over radio frequency ablation and cryoablation, which are susceptible to vascular heat sinks and can thermally injure adjacent structures. This is the first known clinical experience evaluating outcomes in 20 patients with cT1a renal tumors. Imaging outcomes appear to mirror those of cryoablated tumors with ablation site contraction and resorption through time. Oncologically outcomes are immature. Two patients required salvage ablation and 1 underwent partial nephrectomy 1 year after IRE. Jeffrey A. Cadeddu, MD Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Intraoperative Continuous Norepinephrine Infusion Combined with Restrictive Deferred Hydration Significantly Reduces the Need for Blood Transfusion in Patients Undergoing Open Radical Cystectomy: Results of a Prospective Randomised Trial P. Y. Wuethrich, U. E. Studer, G. N. Thalmann and F. C. Burkhard Departments of Anaesthesiology and Pain Therapy, and Urology, Inselspital, University Hospital Bern, Bern, Switzerland Eur Urol 2014; 66: 352e360. doi: 10.1016/j.eururo.2013.08.046 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24012203available at http://www.ncbi.nlm.nih.gov/pubmed/24012203 Editorial Comment: In an attempt to decrease blood loss and the need for transfusion the authors examined the use of continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer maleate solution. In this double-blind, randomized, parallel group, single center trial 166 consecutive patients without severe hepatic or renal dysfunction or congestive heart failure were given either this combination or only Ringer maleate solution throughout surgery. Median total blood loss was 800 ml (range 300 to 1,700) in the norepinephrine/low volume group vs 1,200 ml (400 to 2,800) in the control group (p <0.0001). In the norepinephrine/low volume group 27 of 83 patients (33%) required an average of 1.8 U packed red blood cells. In the control group 50 of 83 patients (60%) required an average of 2.9 U packed red blood cells during hospitalization. Absolute reduction in transfusion rate throughout hospitalization was 28% (95% CI 12e45). The authors, renowned leaders in bladder cancer treatment and cystectomy, should be applauded for their careful and educated approach to moving the field forward. The possible harmful effects of blood transfusion on patient outcomes and survival have become increasingly well recognized. Attempts have previously been made to minimize blood loss with manipulation of intraoperative fluid management. Although difficult to quantify, the authors attempt to characterize the operative field as a “dryer” field, saying it only slightly compromised or did not interfere with the dissection. One does not need level I evidence that a dryer surgical field results in better visualization. The positive impact of this perioperative intervention appears clear, although its universal applicability at other centers and its safety profile with a more heterogeneous cohort of patients must be further examined. In addition, its potential benefit may be muted in a robotic approach, where blood loss and transfusion rates are consistently lower compared to open cystectomy.