Operative Bed Research Articles

Local Anesthesia With 1% Lidocaine Versus General Anesthesia for Percutaneous Endoscopic Interlaminar Discectomy at L5/S1 Disc Herniation​​​: A Prospective Randomized Study.

A prospective randomized clinical trial. In this study, we compared local anesthesia with 1% lidocaine (LA) and general anesthesia (GA) utilized in PEID at L5/S1 disc herniation. Given the anatomic characteristics of L5/S1 segment, interlaminar approach was preferred to perform endoscopic discectomy for L5/S1 disc herniation. Typically, general anesthesia was used for interlaminar approach. However, with general anesthesia, nerve damage during surgery due to being unable to monitor patient status is a main concerned for surgeons. As an alternative option, local anesthesia has been developed recently. But, the optimal type of anesthesia for PEID remains controversial. From March 2021 to March 2023, 103 consecutive patients with L5/S1 disc herniation who planned to undergo PEID in our unit were randomized to the LA group (n=53) or GA group (n=50). Both groups were followed up for at least 24 months. Surgical-related parameters, clinical outcomes, and complications were compared between the 2 groups. The mean operative time and bed rest time were shorter in the LA group than in the GA group (both P<0.001). The estimated blood loss in the LA group was greater than that in the GA group (P<0.001). The cost of hospitalization in the LA group was significantly lower than that in the GA group (P<0.001). At every time point of follow-up, there was no significant difference between the 2 groups in terms of VAS, ODI, and modified MacNab criteria. The satisfaction surveys showed that more patients in the LA group would choose contrary anesthesia, including 6 patients who were administered extravenously injected sufentanil intraoperatively due to intensive pain. Postoperative neuropathic abnormalities were rarer in the LA group. Both local anesthesia using 1% lidocaine and general anesthesia are effective and safe for PEID at the L5/S1 segment. The use of local anesthesia is preferable due to its associated reductions in operative time, bed rest duration, and economic costs.

Surgical Strategies for Renal Transplantation: A Pictorial Essay.

This pictorial essay aims to navigate through the complexities and challenges of renal transplantation (RT), by weaving together visual imagery with clinical insights within a comprehensive illustrative surgical guide. Herein, we provide a detailed visual exploration of the intricate anatomy and surgical processes necessary for both renal graft retrieval from the donor and also for an adequate implantation in the recipient. Regarding graft retrieval, after reviewing the relevant retroperitoneal surgical anatomy, and donor nephrectomy techniques, graft preservation and optimal backbench graft dissection principles were meticulously analyzed. Thereafter, the recipient surgical strategy for graft implantation was addressed, focusing on preoperative preparations, the site of implantation selection, exposure, operative bed dissection, graft revascularization, and urinary tract reconstruction. Careful donor and recipient selection, meticulous surgical execution, and rigorous postoperative management clearly hold a pivotal role in optimizing patient outcomes. Fostering a deeper understanding of the surgical nuances and clinical management practices that contribute to successful results post-RT, we hope to provide a useful practical tool for clinicians about to embark on the treacherous road of RT surgery. Innovative technologies and surgical practices that have already significantly improved the safety and effectiveness of RT stand testament to the importance of further scientific inquiry, conceptual developments, and clinical integration. Moving forward, it is essential that the medical community continues to refine these strategies and advocate for equitable access to transplantation, ensuring that advancements in the field translate into real-world benefits for all patients grappling with ESRD. The collaborative efforts of multidisciplinary teams are essential in addressing the complex clinical challenges associated with RT, with the ultimate goal of improving patient survival, enhancing graft longevity, and reducing healthcare disparities.

Management strategy for children with ovarian immature teratoma: results from a tertiary pediatric oncology center

ObjectivesWe present an Egyptian study on pediatric ovarian immature teratomas (ITs), aiming to clarify our treatment strategy selection.MethodsA retrospective review of all children with pure ovarian ITs who were treated at our institution between 2008 and 2023. The analysis included clinical characteristics, tumor staging according to Children’s Oncology Group (COG), grading based on the Norris system, management, and outcomes.ResultsThirty-two patients were included, with a median age of 9 years. All patients underwent primary surgery. Unilateral salpingo-oophorectomy was performed in 31 patients. Surgical staging was completed in all patients. Based on COG staging, there were 28 patients (87.5%) stage I, 1 (3%) stage II, and 3 (9.5%) stage III. According to Norris classification, 16 patients (50%) were classified as grade I, 9 (28%) grade II, and 7 (22%) grade III. All patients in stage I were treated using surgery-alone approach, whereas the remaining four (12.5%) received adjuvant chemotherapy. Five patients in stage I had gliomatosis peritonei (GP), and none of them underwent extensive surgery. At a median follow-up of 86 months, two patients had events. The first patient (stage III/grade I) developed IT relapse on the operative bed, and the second (stage I/grade I) had a metachronous IT on the contralateral ovary. Both patients were successfully managed with surgery followed by second-line chemotherapy. Five-year overall survival and event-free survival for all patients were 100% and 93.4%, respectively.ConclusionsSurgery-alone strategy with close follow-up achieves excellent outcomes for localized ovarian ITs in children, irrespective of the Norris grading or the presence of GP. However, adjuvant chemotherapy is questionable for patients with incompletely resected or locally advanced tumors, and its role requires further evaluation through prospective multicentric studies with a larger sample size.

Artificial intelligence as a negative predictive tool for breast cancer postoperative recurrence

BackgroundMammography alone is an ineffective method for breast cancer surveillance and diagnosing cancer recurrence. The aim was to evaluate the ability of artificial intelligence (AI) to read digital mammograms as an additive tool to exclude recurrence in the operative bed of known breast cancer patients following the different surgical procedures.MethodsWe used a retrospective cohort study of post-surgery mammograms (n = 577). Imaging was performed within 6 months after the surgery or more. The AI solution used to read mammograms (AI-MMG) provided a targeted heat map of the operative bed, which was supported by a decision likelihood score percentage of cancer recurrence. The reference for suspicious or malignant-looking abnormalities (n = 62, 12.3%) was diagnosed by biopsy. A clear operative bed and benign-looking changes (n = 442) were confirmed by ultrasound characterization patterns and one year of intermittent follow-up.ResultsThe AI scoring percentage for a clear operative bed ranged between 0 and 26%, with a mean of 15% ± 5.4%. Operative bed benign changes ranged from 10 to 88%, with a mean of 48.2% ± 21.2%, while malignancy recurrence ranged from 65 to 99%, with an average of 87.7% ± 10.5%. The “ROC: Receiver Operating Characteristic” curve for AI to predict cancer in the surgical bed on mammograms was 0.906. The optimum cutoff value to distinguish between benign postoperative alterations and malignancy recurrence was 56.5% (95%, CI 0.824–1.060, p value < 0.001).Excellent agreement between AI-MMG and pathology or ultrasound results was observed, and Kappa was 0.894, p value < 0.001.ConclusionsThe use of artificial intelligence has enhanced the diagnostic performance of the postoperative mammograms to rule out recurrent malignancies in breast cancer surveillance.

Role of Artificial Intelligence (AI) in physiotherapy

With the growing demand of technological advancements and real time technical support, ARTIFICIAL INTELLIGENCE (AI) has emerged as one of the integral parts of the healthcare system, especially after post pandemic era (1) Synthetic intelligence plays a significant role in assessment and patient management. So, the time is not far where learning and implementing it in current practice will be the need of an hour. Physiotherapy course curriculum would need to add it on in the coming times to become rational about accepting or rejecting the AI advices. With the fast paced growing time, at times it becomes difficult for patients to even visit physiotherapy clinic on a daily basis or the post operative bed ridden patients or individuals who are bed ridden due to other reasons such as stroke, spinal cord injury or other neurological impairment, home bases treatment with AI instruments can prove nothing less than a blessing

Multimodality Dosimetric Evaluation for the Treatment of Recurrent Brain Tumors

GammaTile Surgically Targeted Radiation Therapy (STaRT) are bioresorbable collagen tiles containing four Cesium-131 radioactive seeds which are permanently implanted into the operative bed immediately following the surgical resection of a brain tumor. Alternative radiation treatment approaches for recurrent brain tumors include external beam radiation therapy (EBRT) with either proton or photon (volumetric modulated arc therapy, or VMAT) radiation. The purpose of this study is to perform a comparative dosimetric study of these three modalities for cases of recurrent brain tumors. We hypothesize that GammaTile would be dosimetrically superior at sparing radiation dose to surrounding organs at risk. A total of 5 patients have received GammaTile StaRT therapy at our institute for recurrent brain tumors in 2021-2022. Out of these 5 patients, 3 were recurrent glioblastoma (GBM) and 2 were brain metastasis (brain-met) cases. All patients were previously treated with radiation. Typical prescription for GammaTile therapy is 60 Gy to the High Risk CTV (HR_CTV), specified by 5mm depth from the plane of the seeds. For recurrent GBM cases, the alternative methods of radiation are proton therapy and photon therapy using VMAT. The standard re-irradiation dose for proton and photon therapy is 35 Gy in 10 fractions prescribed to PTV (3 mm expansion of EBRT CTV). For brain-met cases, an alternate method is hypo-fractionation radiation therapy with Linac-based SBRT. Linac-based SBRT prescription depends on the volume of EBRT CTV. For one of the brain-met cases, the SBRT prescription was 30 Gy in 5 fractions, and for the other case it was 27 Gy in 3 fractions to PTV (2 mm expansion from EBRT CTV). Proton and photon plans were generated in a treatment planning system using a double scattering Mevion system and a VersaHD with agility head, respectively. All the physical doses were converted to biological effective dose (BED) for evaluation. The dosimetric quantities are summarized in table 1. These quantities were evaluated using HR_CTV and EBRT_CTV for GammaTile therapy and EBRT (proton/photon), respectively. GammaTile therapy reduces dose to normal brain tissue considerably. However, it may have more uncertainty in the dose delivered compared to proton and photon EBRT. It appears that all three treatment modalities are adequate for treating recurrent brain tumors. However, GammaTile therapy may allow to deliver higher dose to the targets while reducing the irradiation to adjacent normal tissue.

Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience

We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution. After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes. The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity. RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.

Early decompressive surgery within 72 hours of admission maintains financial advantages for patients with spinal epidural abscess, as evidenced by a retrospective study involving 130 cases

Abstract Background Several recent studies have highlighted the advantages of early decompressive surgery for patients with spinal epidural abscesses, specifically in terms of neurological function and overall quality of life. However, these studies predominantly advocate for surgery within 24 hours of admission, a time frame that may prove challenging for many hospitals because of limited operating room availability and bed occupancy. Consequently, it is pertinent to investigate whether a more flexible definition of “early surgery” yields observable benefits for patients to address these practical constraints. Materials and Methods In this 10-year retrospective study, we analyzed the electronic medical records of 130 patients who underwent decompressive surgery for epidural abscess. Patients were categorized into three groups based on the time intervals between admission and surgery: ≤24 hours (n = 24), 24 to 72 hours (n = 26), and &gt;72 hours (n = 80). Comparative assessments of demographic data, clinical presentations, and preoperative imaging characteristics revealed no statistically significant differences. We conducted separate analyses at 24 hours (n = 24 vs n = 106) and 72 hours (n = 50 vs n = 80) to explore the effects of different cutoff times. Neurological improvement (American Spinal Injury Association Impairment Scale [AIS] grade), daily living function (modified Prolo scale) changes 6 months postdischarge, and financial burden (hospitalization and postoperative stay duration, total expenditure) were evaluated as outcome measures. In addition, we compared the outcomes of patients within the 24- to 72-hour time range with those in the ≤24- and &gt;72-hour group to determine any differences among the three groups. Results Significant changes in AIS grade (1.17 vs 0.66, P = 0.019) and modified Prolo scale (4.21 vs 2.90, P = 0.011) were observed in the 24-hour group, whereas no such changes were seen in the 72-hour group. However, both groups showed reductions in financial burden, including hospitalization duration (24-hour group: 27.8 vs 46.8 days, P &lt; 0.001; 72-hour group: 31.3 vs 50.7 days, P &lt; 0.001) and total cost (24-hour group: $6551 vs $11,024, P &lt; 0.001; 72-hour group: $6709 vs $12,406, P &lt; 0.001). When analyzing the subgroup of patients with a time interval between 24 and 72 hours, we observed a loss of beneficial effects on AIS grade changes (1.2 vs 0.6, P = 0.045) and modified Prolo scale improvement (4.2 vs 3.1, P = 0.044) compared with the ≤24-hour group. However, this subgroup still exhibited positive effects in terms of reduced financial burden, including hospitalization duration (34.6 vs 50.7 days, P = 0.002) and total cost ($6851 vs $12,406, P &lt; 0.001), when compared with the &gt;72-hour group. Conclusions Our findings indicate that delaying decompressive surgery up to 72 hours after admission negates its benefits in enhancing neurological recovery and restoring daily life capacity. Nonetheless, this surgical approach continues to provide financial advantages by alleviating the financial burden on patients and the health care system. Further research with a larger sample size is recommended to deepen our understanding of these advantages.

132 Pseudoaneurysm of the Facial Artery After Tonsillectomy Managed with Endovascular Coiling: A Case Report

Abstract Introduction We present a case of pseudoaneurysm of the facial artery after tonsillectomy managed with successful endovascular coiling. Presentation of Case 41-year-old lady presented with a history of throat pain and 3 episodes of hematemesis on the 3rd, 4th, and 7th postoperative days after tonsillectomy and styloidectomy. She had undergone the operation 20 days back. Neurological examination was normal. Contrast-enhanced computed tomography scan of the neck showed – contrast-filled dilatation of a branch of the right facial artery in the right palatine tonsillar fossa within the operative bed – likely pseudoaneurysm which was managed endovascularly. The patient recovered fully after treatment. Discussion Tonsillectomy can have various complications among which one is the pseudoaneurysm of the facial artery which can be managed with coiling in the catheterization laboratory. Conclusions Pseudoaneurysm of the facial artery is a rare complication of tonsillectomy. Endovascular treatment of a pseudo aneurysm can be done.

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique.

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11mm endoscope port was placed on the midline 2cm above the umbilicus. Another two 8mm robotic ports were symmetrically placed under vision on a transversal line-located 1cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35min; console time up to urethral dissection was 150 and 140min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

High capacity aluminium substituted hydroxyapatite incorporated granular wood charcoal (Al-HApC) for fluoride removal from aqueous medium: Batch and column study

In this study, aluminium substituted hydroxyapatite (Al-HAp) was synthesized in-situ on granular commercial wood charcoal at room temperature for fluoride removal from groundwater. Granular size (0.5–3.0 mm) of the carbon particles was selected considering the practical application of the final adsorbent in a packed-bed column filter. The adsorbent was characterized thoroughly. The Al-HAp phase was precipitated inside the pore channel as well as on the surface of highly porous wood charcoal matrix. The adsorbent had surface area of 442 m2/g and pHzpc value was 5. The maximum fluoride adsorption capacity at 303 K was achieved as 105 mg/g which is the highest for any granular adsorbent reported till date for adsorption of fluoride. Batch studies were used to deduce the effective role of pH, temperature and ion selectivity on adsorption efficiency. The reusability of the media was tested upto five cycles after consecutive regeneration with 1 M NaOH. Using the developed media, continuous column run experiments were conducted at different operating conditions, viz., bed volume, flow rate and feed concentration. The maximum number of bed volume was obtained as 1415 for a 30 cm bed height with flow rate 10 L/day and feed concentration of 3 mg/L. A fundamental mass transport model based on pore-diffusion was used to simulate breakthrough behavior in fixed-bed column runs with the synthetic and real contaminated groundwater. The relevant model parameters, namely, fixed bed mass transfer coefficient (kfb), effective pore diffusivity (Dp) and the coefficient of axial dispersion (Ez) were estimated.

E004 Inpatient admission pathway for patients with rheumatological disorders

Abstract Background/Aims Rheumatology is a complex specialty covering many conditions of varying severity, from muscle pain through inflammatory arthritis such as Rheumatoid arthritis (RA) and connective tissue diseases. Most of the conditions can be managed in an outpatient/day case setting. However, acutely ill patients require safe and prompt inpatient management including specific intravenous infusions. This need to be done urgently and cannot wait to be accommodated through the Infusion unit at our hospital. Historically Medicine Acute Admission Unit has been the route to bring in these patients. However, operational bed pressures faced challenges leading to instances of delayed treatment with complications including fatality. This led to creating a direct inpatient admission pathway to the specialist ward. Methods Ward Matron designed the following robust pathway for direct patient admission to our specialist Rheumatology ward, Jevington ward. This was implemented in February 2022 after discussion and agreement with Clinical Lead consultant, pharmacist, clinical site managers and other colleagues. Rheumatology team and nurses covered the ward during working hours and by the on-call team out of hours. The overall responsibility remained with the rheumatology team. The referrals accepted only after completing appropriate paperwork. Patients carried out Lateral Flow Test (LFT) at home prior to admission. We ensured negative results and followed the Trust COVID 19 screening protocols. Subsequent screenings were done according to the updated guidelines. The planned assessment and treatments were carried out by the ward team complying with BSR/EULAR Guidelines, infusion protocols such as standard and continuous Iloprost Infusion Protocols of the Trust. Results We assessed the delay in patient's admission, length of stay, patient outcome and experience after implementing the pathway. The significant change has been in the time to admit; from two weeks in 2018 &amp; 19 to two days this year. This is reflected in the patient feedback. All our acutely ill patients were assessed, treated and discharged promptly on this specialist ward. Conclusion This pathway allowed safe and prompt treatment, prognosis and excellent experience for acutely ill patients with rheumatological disorders. This additionally enabled reduced length of stay supporting financial sustainability of the Trust. Disclosure S. Panthakalam: None.

The comparison of femoral neck system and cancellous screws internal fixation for femoral neck fracture

ABSTRACT Background The clinical efficacy of cancellous screws (CS) and femoral neck system (FNS) internal fixation in the treatment of femoral neck fracture (FNF) was compared in this research. Methods Ninety-six patients with FNF were enrolled in this study. There were 47 cases in FNS group and 49 cases in CS group. The data of operation time, intraoperative bleeding, bed days and complication were recorded. Patients’ joint function was evaluated by Harris score. At the last follow-up, the cost-effectiveness analysis of the two methods was analyzed according to the total cost of patients and hip function. Results The intraoperative blood loss of the patients in FNS group was significantly higher than that in the CS group, but the length of hospitalization was significantly lower. There was no significant difference in the incidence of complications between FNS and CS. The joint function of FNS group was significantly better than that of CS group at 3 months after operation. There was no significant difference in Harris score between the two groups at the last follow-up. The overall medical cost of FNS group in 1 year is high. Cost-effectiveness analysis showed that compared with CS group, FNS group needs to pay 5761.1 yuan more for each additional Harris score. Conclusion FNS and CS internal fixation can achieve satisfactory clinical results in the treatment of FNF. FNS treatment is helpful to the early functional recovery of patients, but the overall medical cost is high.

V01-06 ROBOT-ASSISTED PYELOPLASTY WITH THE NOVEL HUGO TM RAS SYSTEM: SURGICAL SETUP AT A HIGH VOLUME ROBOTIC CENTER

You have accessJournal of UrologyCME1 Apr 2023V01-06 ROBOT-ASSISTED PYELOPLASTY WITH THE NOVEL HUGOTM RAS SYSTEM: SURGICAL SETUP AT A HIGH VOLUME ROBOTIC CENTER Maria Peraire Lores, Carlo Bravi, Marco Paciotti, Luca Sarchi, Luigi Nocera, Adele Piro, Eleonora Balestrazzi, Angelo Mottaran, Federico Piramide, Rui Farinha, Geert De Naeyer, Alexandre Mottrie, and Ruben De Groote Maria Peraire LoresMaria Peraire Lores More articles by this author , Carlo BraviCarlo Bravi More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Adele PiroAdele Piro More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Angelo MottaranAngelo Mottaran More articles by this author , Federico PiramideFederico Piramide More articles by this author , Rui FarinhaRui Farinha More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , and Ruben De GrooteRuben De Groote More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: New surgical robots with various technical enhancements are gaining popularity in urology and may increase the use of robotics also in non-oncological fields. HUGO RAS system is a robotic platform with independent arm carts and an open console. Here, we presented our first robot-assisted pyeloplasty with HUGO RAS system with the aim to describe technical feasibility and surgical setup of this novel robotic platform for benign kidney surgery. METHODS: A 36-year-old male, without previous abdominal surgeries, was diagnosed with a left pyeloureteral junction stenosis. The CT scan showed a left kidney hydronephrosis with a pelvis diameter of 6 cm with a delayed urinary excretion. The MAG-3 scan showed left and right renal function of 27% and 73%, respectively. A robot-assisted left pyeloplasty was performed through a transperitoneal approach with the HUGO RAS system. With the patient in right lateral decubitus, a 12-mm Airseal trocar was placed 2 cm lateral to the umbilicus, on the left pararectal line. Other two 8-mm robotic ports and an 11-mm optic port were placed under vision in a diamond configuration (Figure 1), all of them 8 cm apart from each other and 2 cm away from bone prominences; lastly, an 8-mm port was placed in the left lower quadrant. In order to optimise working space, three arm carts (corresponding to surgeon’s left hand, optic and forth robotic arm, respectively) were positioned behind the operative bed, whereas one arm cart (i.e. surgeon’s right hand) was placed in front of the patient. RESULTS: The patient was classified as ASA 1 and had a preoperative creatinine of 1.16 mg/dl. Operative and console time were 95 and 70 minutes, respectively. No intraoperative complications occurred, and blood loss was <20 cc. No technical problems, instruments or arms clashes were reported. The patient was discharged the second postoperative day with a creatinine of 1.02 mg/dl. No perioperative complications were reported. CONCLUSIONS: Robot-assisted pyeloplasty using the new HUGO RAS system is safe, feasible and it guarantees optimal perioperative and early functional outcomes. Awaiting study with longer follow-up, our data showed that HUGO RAS might be considered a valuable treatment option for benign kidney surgery, providing relevant information for future adopters of this surgical platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e80 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maria Peraire Lores More articles by this author Carlo Bravi More articles by this author Marco Paciotti More articles by this author Luca Sarchi More articles by this author Luigi Nocera More articles by this author Adele Piro More articles by this author Eleonora Balestrazzi More articles by this author Angelo Mottaran More articles by this author Federico Piramide More articles by this author Rui Farinha More articles by this author Geert De Naeyer More articles by this author Alexandre Mottrie More articles by this author Ruben De Groote More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE”

You have accessJournal of UrologyCME1 Apr 2023V10-04 STEP-BY-STEP DESCRIPTION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY WITH THE NOVEL HUGO RAS ROBOTIC SYSTEM USING THE “AALST TECHNIQUE” Marco Paciotti, Carlo Andrea Bravi, Mottaran Angelo, Luigi Nocera, Luca Sarchi, Rui Farinha, Adele Piro, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Frederiek D'Hondt, Geert De Naeyer, Aalst, Belgium, Ruben De Groote, and Alexandre Mottrie Marco PaciottiMarco Paciotti More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Mottaran AngeloMottaran Angelo More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Rui FarinhaRui Farinha More articles by this author , Adele PiroAdele Piro More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Frederiek D'HondtFrederiek D'Hondt More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Aalst Aalst More articles by this author , Belgium Belgium More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The HUGO™ RAS is a competitor for leadership in the field of robotic surgery. However, concerns remain about the ease of use of this device by new adopters. We performed the first robot-assisted radical prostatectomy (RARP) procedure in Europe with Hugo RAS. In this video, we described our surgical technique for bilateral nerve-sparing (NS) RARP performed using this novel platform. We also reported surgical setting and outcomes of our case series. METHODS: The procedure shown in the video was performed by an experienced robotic surgeon (AM) using HUGO RAS in March 2022. This robotic platform consists of four independent arm carts, novel design hand controllers and an open console. We described a RARP performed according the “Aalst technique”, including useful surgical tips. Moreover, we reported perioperative, pathological and short-term functional outcomes of consecutive patients affected by low- or intermediate-risk prostate cancer (PCa) who underwent NS RARP with HUGO RAS between February and October 2022 at our Center. RESULTS: Patients were in Trendelemburg position. One eleven-mm endoscope port was placed on the midline above the umbilicus, while other three 8 mm robotic ports were placed on a transversal line 5 cm below the optic port. Two laparoscopic ports were positioned in the right hemi-abdomen. Three arm carts were docked from the left of the operative bed, and one from the right. RARP was performed with a trans-peritoneal, anterior approach following validated metrics. Some of the specific characteristics our of technique, described in the video, are: sparing of the median umbilical ligament, postero-lateral approach to the bladder neck, antero-lateral release of the neurovascular bundles, dissection of the apex according to the “collar technique”, posterior muscolofascial reconstruction incorporated into urethrovesical anastomosis. Overall, 76 patients affected by low- or intermediate-risk PCa underwent RARP with HUGO RAS using this technique. In every case, all the steps of the procedure were completed. No intraoperative complication was recorded. Full outcomes are reported in the video. CONCLUSIONS: In this video, we described a step-by-step NS RARP performed according to our technique using the novel HUGO RAS. We provided useful tips to perform critical phases of the procedure. Experienced surgeons were able to easily perform all the surgeries with optimal perioperative, pathological, and functional outcomes. Therefore, we showed that surgical experience can be easily transferred to this novel platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e927 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Carlo Andrea Bravi More articles by this author Mottaran Angelo More articles by this author Luigi Nocera More articles by this author Luca Sarchi More articles by this author Rui Farinha More articles by this author Adele Piro More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Frederiek D'Hondt More articles by this author Geert De Naeyer More articles by this author Aalst More articles by this author Belgium More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

Risk factors for sialocele after parotidectomy: Does tumor size really matter?

ObjectiveSialocele that develops after parotid surgery often prolongs the treatment period and stresses both the surgeon and patient. The extent of surgery and tumor size are known to be associated with sialocele occurrence. We investigated the incidence of post-parotidectomy sialocele and the associated risk factors, with a focus on tumor size. MethodsWe retrospectively reviewed the medical records of 172 patients who underwent parotidectomy between January 2013 and May 2020 at Haeundae Paik Hospital, Inje University of Korea. We stratified patients into those with and without sialocele (fluid collection in the operative bed). We compared clinical data, patient demographics, and surgical details; we identified risk factors for sialocele development after parotid surgery. ResultsSeventeen patients were diagnosed with post-parotidectomy sialocele (9.88%; 17/172). Univariate logistic regression revealed that the male sex, deep lobe tumor location, and large tumor size were significantly associated with postoperative sialocele (p = 0.015, 0.009, and 0.016, respectively). We subjected these parameters to multivariate analyses; the odds ratios were 3.70, 3.58, and 2.34, respectively. Receiver operating characteristic curve analyses showed that a tumor size > 2.50 cm was the optimal cutoff in terms of predicting post-parotidectomy sialocele. ConclusionMale sex, a tumor in the deep lobe, and large tumor size were strongly associated with increased risk for sialocele after parotidectomy. Tumor size > 2.50 cm serves as the cutoff identifying patients likely to experience sialocele after parotid surgery.

New online tool to help providers find open beds for BH care

Approximately one in five individuals in North Carolina has a behavioral health issue, according to the state's health and human services leadership. The situation is further exacerbated by the hundreds of people in the state who each day wait inside hospital emergency departments (EDs) for behavioral health care. One reason is the lack of a real‐time list of available operational beds, making it difficult to connect people in EDs to care in more appropriate settings.

NEW ZEALAND PROVINCIAL ORTHOPAEDIC TRAUMA STUDY (NZPOTS): THE EFFECTS OF INCREASING TRAUMA ON ELECTIVE ORTHOPAEDIC SURGERY IN PROVINCIAL NEW ZEALAND

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity.Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week.Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages.New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance.

Phase I study of proton therapy in adjuvant pancreatic cancer (PROTON-PANC).

709 Background: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, with a 5-year survival rate of 10%. The current standard of care for patients with resectable disease is surgical resection followed by 6 months of adjuvant mFOLFIRINOX (mFFX) chemotherapy. As survival outcomes and distant recurrence rates improve with the use of mFFX, locoregional recurrence remains a significant cause of morbidity and mortality. We sought to integrate short-course proton radiation therapy (PRT) to the operative bed between cycles of adjuvant chemotherapy in patients with resected PDAC of the pancreatic head. Methods: Between 2019 and 2022, patients with resected PDAC with an R0 or R1 resection on adjuvant mFFX were enrolled in a phase I trial using a 3+3 dose-escalation schema (NCT03885284). Patients received mFFX as used in the PRODIGE 24 study and also received short-course PRT delivered over 1 week in 5 fractions (5 GyE each) between cycles 6 and 7 of mFFX. In dose level 1 (DL1), patients received PRT on days 15-19 in a 28-day cycle before starting cycle 7, and in dose level 2 (DL2) patients received PRT on days 8-12 in a 21-day cycle before starting cycle 7. Results: Nine patients were enrolled on the trial, median age 66 (range 52-78). Five had R0 resections, 4 had R1 resections, and 5 had node-positive disease. No patients received preoperative therapy, and none underwent vein reconstruction. Three patients were enrolled on DL1 and 6 patients on DL2. One dose limiting toxicity (DLT) occurred at DL2 (prolonged grade 3 neutropenia resulting in discontinuation of mFFX after cycle 7). No other DLTs were observed. Four patients completed the planned 12 cycles of mFFX (range 7-12, median 11). None of the patients have had local recurrence. Five of 9 patients had recurrence: 3 in the liver, 1 in the peritoneum, and 1 in the bone. Six patients are still alive, 4 of whom are recurrence free. With a median follow up from date of chemotherapy start of 12.5 months, median time to disease recurrence was 12 months (95% confidence interval [CI] 4-not reached [NR]), and median overall survival has not been reached (95% CI 6-NR, 2-year survival rate 57%). Conclusions: PRT integrated within adjuvant mFFX was well-tolerated and no local recurrence was observed for patients with resected PDAC. These findings warrant being confirmed in a phase II trial. Clinical trial information: NCT03885284 .

Gasification of a typical low-rank coal in 65MWth KEDA® circulating fluidized-bed gasifier

The KEDA® circulating fluidized-bed (KEDA®CFB) gasifier is a high-temperature air-blown circulating fluidized bed developed by KEDA (ANHUI) Clean Energy Co., Ltd to produce clean industrial gas. This project describes the design and the initial operating results of using low-rank coal to produce industrial fuel gas in a 65MWth KEDA®CFB industrial-scale plant with a feeding rate of 13 ton/hr. The gasification process was carried out at an ambient pressure and temperatures at 980 ± 10 °C. A long-term stable operation was achieved for more than 20 days. Cold gas efficiency could reach 73% with a gas high heating value of 5.89MJ/Nm3 at a steam-to-coal ratio of 0.38 and an equivalence ratio of 0.3. During the stable operation, it was also observed that the operational bed temperature has to be kept under the residual ash fusion temperatures (AFTs) to avoid aggregation and defluidization.