Single Surgical Team Research Articles

Feasible first trocar insertion technique in bariatric surgery: A novel technique

Although tremendous advancements in bariatric surgery have been made, there is still no universal approach to initial abdominal access. Herein, we describe a novel technique for first trocar entry that is feasible, safe and fast to perform in morbidly obese patients undergoing laparoscopic bariatric surgery. Our aim is to describe a trocar insertion technique in bariatric surgery used as a routine in our obesity clinics and to present its results.The registries from the Tokat Gaziosmanpasa University Hospital recorded between January 2017 and January 2019 were reviewed to retrieve data on morbidly obese patients operated on by a single surgical team using the novel trocar insertion technique.A total of 244 consecutive morbidly obese patients who underwent sleeve gastrectomy and gastric bypass performed by the same surgical team with the same technique were included in this study. Among 244 patients, 224 (91.8%) underwent sleeve gastrectomy, and 20 (8.2%) underwent gastric bypass. The mean body mass index was 46.23 kg/m2 (range 31 – 80 kg/m2). All interventions were performed laparoscopically with no cases of conversion to open surgery. During this study, eight cases of omental (3.27%) and three cases of small bowel mesentery (1.22%) injuries were encountered in 11 different patients (4.5%) and were self-limited; no major bleeding, bowel injuries, gas emboli or deaths occurred. As a conclusion this technique for direct trocar entry in morbidly obese patients is considered to be safe since no major complications occurred, fast because no dissection or time-consuming steps were required and finally, feasible because the trocar insertion procedure is straightforward.

Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve.

Introduction:The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol.Methods:After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis.Results:Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50–82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191–370) and 80 min (range: 65–90), respectively. The median estimated blood loss was 300 cc (range: 50–500). The median length of stay was 8 days (range: 4–30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1–17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1–34).Conclusions:While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.

Laparoscopic versus open surgical management of patients with Mirizzi's syndrome: A comparative study.

Introduction:Open surgical management is considered as ‘standard of care’ for patients with Mirizzi's syndrome (MS). Laparoscopic management of MS has been reported, but comparative studies are lacking.Patients and Methods:This retrospective study included patients with MS who were treated by a single surgical team from May 2009 to December 2017. Patients with total laparoscopic surgery were included in laparoscopic group (LG) and patients with total open surgery were included in open group (OG). Patients with conversion to open surgery and patients with gallbladder cancer (GBC) were excluded from the study.Results:Total patients were 75; six patients with GBC and 11 patients with open conversion were excluded from comparison. LG had 32 patients and OG had 26 patients. Demographic, clinical and laboratory parameters were similar. Laparoscopic versus open preoperative diagnosis rate was 87.5% versus 69.2% (P = 0.08), respectively. OG had a large number of patients with concomitant bile duct stone; therefore, bile duct exploration rate was higher in OG (P = 0.009). Laparoscopic versus open, mean duration of surgery – 137 min versus 145 min (P = 0.664); mean blood loss – 45 mL versus 70 mL (P = 0.04); mean hospital stay – 4.5 versus 8.1 days (P = 0.027). Post-operative complication rate was 21.8% in LG and 42.3% in OG (P = 0.355); bile leak was noted in OG only (P = 0.042). LG versus OG mean follow-up was 50 versus 38 months (P = 0.189); no remote complication was observed in both groups.Conclusion:The results of laparoscopic surgery in patients with Mirizzi's syndrome are not inferior to that of open surgery; rather it may help to improve perioperative outcome in selected patients.

Low-risk prostate cancer in India: Is active surveillance a valid treatment option?

Introduction and Objective:Carcinoma prostate is considered highly aggressive in Asian countries such as India. This raises an argument whether active surveillance (AS) gives a false sense of security as opposed to upfront radical prostatectomy (RP) in Indian males with low-risk prostate cancer (PCa). We analyzed our prospectively maintained robot-assisted RP (RARP) database to address this question.Materials and Methods:Five hundred and sixty-seven men underwent RARP by a single surgical team from September 2013 to September 2019. Of these, 46 (8.1%) were low risk considering the National Comprehensive Cancer Network criteria. Gleason grade group and stage were compared before and after surgery to ascertain the incidence of upgrading and upstaging. Preoperative clinical and pathological characteristics were analyzed for association with the probability of upstaging and upgrading.Results:The mean age was 60.8 ± 6.8 years. Average prostate-specific antigen level was 6.7 ± 2.0 ng/mL. 40 (86.9%) patients had a T1 stage disease and 6 (13%) patients were clinically in T2a stage. A total of 25 (54.3%) cases were either upstaged or upgraded, 19 (41.3%) showed no change, and the remaining 2 (4.3%) had no malignancy on the final RP specimen. Upstaging occurred in 8 (17.4%) cases: 5 (10.9%) to pT3a and 3 (6.5%) to pT3b. Upgrading occurred in 23 (50%) cases: 19 (41.3%) to Grade 2; 3 (6.5%) to Grade 3; and 1 (2.2%) to Grade 4.Conclusions:There is a 50% likelihood of upstaging or upgrading in Indian males with low-risk PCa eligible for AS. Decision to proceed with AS should be taken carefully.

Modified Closed Coronary Transfer is a Good Alternative to the Trap-Door Method During Arterial Switch Operation: a Retrospective Propensity-Matched Comparison.

Objective To compare the early and long-term results of patients in whom was performed modified closed coronary transfer with the results of patients in whom was performed trap-door transfer techniques by utilizing propensity-matching analysis to provide optimal identical patient matching for the groups.Methods From August 2015 to December 2017, 127 consecutive patients underwent arterial switch operation due to simple and complex transposition of the great arteries, with or without additional arch and complex coronary pattern, by a single surgical team included into the study. Of these, in 70 patients it was performed modified closed coronary transfer technique and in 57 patients it was performed trap-door style coronary transfer technique. The patients were divided into two groups in terms of coronary transfer method. In the final model, after propensity matching, 47 patients from each group having similar propensity score were included into the study.Results There was no significant difference between the groups regarding patient characteristics. Cross-clamp time and operation time were significantly lower in the modified technique group compared with the other group (P=0.03 and P=0.05, respectively). When compared the early and late postoperative outcomes, there was no significant difference between the groups. Postoperative echocardiographic findings were mostly similar between the groups.Conclusion The patients in whom was performed our modified technique demonstrate overall good outcomes and the current technique ensures shorter arterial cross-clamp and operation times. It may be an alternative method to the trap-door technique for the coronary transfer during the arterial switch operation.

The effect of performing two pancreatoduodenectomies by a single surgical team in one day on surgeons and patient outcomes

BackgroundThe centralization of pancreatoduodenectomy (PD) has been shown to improve patient outcomes. The scheduling of two PDs in one day is one option to shorten the waiting time for patients referred to high volume centers. The effect on the surgical team or patient outcomes of such an approach have not previously been explored. This study aimed to investigate the effect of scheduling two PDs in one day on the surgeon's workload and patient outcomes. MethodsA retrospective review of patients undergoing PD by a single surgeon between 2007 and 2018 was performed. Patients were allocated into: first PD (FIRSTPD group) or second PD (SECONDPD group) according to the position on the surgical operating list. The intraoperative, postoperative outcomes, and workload (the Surgery Task Load Index; SURG-TLX) were assessed between two groups. ResultsA total of 967 (91%) and 101 (9%) patients were included in the FIRSTPD and SECONDPD group, respectively. There were no differences in the duration of surgery (coefficient = −9.65; 95% confidence interval: −29.26 to 9.94; P = 0.334), incidence of major complications (odds ratio = 1.08; 95% confidence interval: 0.67–1.73; P = 0.739), or 90-day mortality (odds ratio = 1.03; 95% confidence interval: 0.12–8.53; P = 0.978) for those patients in the SECONDPD group as compared to the FIRSTPD group. The mean scores of two (physical and temporal demand) of the six SURG-TLX subscales of surgical workload were recorded as significantly higher by surgeons following two PD's as compared to one PD. ConclusionsAlthough scheduling a second PD in one day shows no association with adverse patient outcomes, there is an increase in the physical and temporal subscales of surgical workload and consideration should be given to how this could be minimized.

Extraperitoneal approach robotic-assisted urethra-sparing simple prostatectomy for large-gland benign prostatic hyperplasia: initial experience

Objective To report our initial experience with extraperitoneal approach Robotic-Assisted Urethra-sparing simple prostatectomy(US-RASP)on large-gland (>100 ml) benign prostatic hyperplasia(BPH). Methods From August 2015 to April 2018, 32 patients with large volume prostate underwent US-RASP performed by single surgical team were retrospectively reviewed. The patient's median age was 73 (range 59-80) years, and median BMI was 24.9 (19.3-34.8 ) kg/m2, The estimated prostate volume(V), postvoid residual volume(PV) by transrectal ultrasonography and PSA were 152.0(119.0-223.1)ml, 145(0-280)ml and 13.7(5.2-27.3)ng/ml, respectively. Four of 32 patients underwent preoperative urinary catheterization. The perioperative functional parameters including international prostate symptom score (IPSS) questionnaire, maximum flow rate (Qmax), maximum voided volume(Vmax), quality of life questionnaires (QOL) and International Index of erectile function-erectile function (IIEF-EF) were 27(23-33), 5.9 (2.5-7.8) ml/s, 110 (80-210)ml, 5(3-6), and 27(26-29), respectively. Functional parameters including IPSS, QOL, Qmax, Vmax, PV and IIEF-EF were compared and analyzed at 3 and 12 months postoperatively during the following-up. Results The US-RASP was completed in all 32 patients and no open conversion. Median operation time was 180 (115-240) min, the estimated blood loss was 300(range 100 to 400)ml, Hemoglobin loss was 17(5-38)g/L. The median Foley catheterization time was 7 (5-12) days and drainage was removed after a median of 5 (4-7) days with median hospital stay of 8(6-14)days. Median specimen weight on pathological examination was 107.7 (79.8-147.4)g with median of 64.2% (49.4%-86.2%) resection ratio. At 3-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 6(4-18), 17.3 (13.8-21.1)ml/s, 167(140-310)ml, 50(0-61)ml, 1(0-3) , respectively. At 12-mo follow-up, median IPSS score, Qmax, Vmax, PV and QOL were 4(1-9), 20.1 (17.9-24.1)ml/s, 205(176-305)ml, 24(0-35)ml and 1(0-2) , respectively. All patients showed great improvement of IPSS, Qmax, Vmax, PV and QOL after median 17 (12-44) months follow-up compared with preoperative parameters (P<0.05). Erectile function was not impaired in 17 patients who have normal erectile function pre-operatively and 14 cases (82.4%) preserved satisfactory anterograde ejaculation. No significant complication occurred during the procedure. No patient developed permanent urinary incontinence. Conclusions US-RASP is a safe and effective treatment option for selected patients with large-gland obstructive BPH(>100 ml). Our data showed significant improvement in voiding function and maintaining satisfactory anterograde ejaculation following urethral-sparing technique. It may be a new alternative method in the future for large-volume symptomatic BPH. Key words: Prostatic hyperplasia; Prostatectomy; Robotic-assisted surgery; Extraperitoneal approach; Urethra-sparing

2 Methods for Identification and Preservation of Hypogastric Nerve During Laparoscopic Die (Deep Infiltrating Endometriosis) Surgery

Video Objective In this video, we are going to introduce two methods for proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery. Setting Single institute, single surgical team's experience. Interventions USL is the mostly frequently involved area of pelvic endometriosis. Hypogastric nerves just lie between USL and pelvic ureter, locate in the Okabayashi pararectal space. They are frequently involved (either direct infiltration, or just encasement by surrounding tissue fibrosis) by the DIE lesions. En-bloc excision of USL DIE lesions frequently result in inadvertent hypogastric nerve injury, or even pelvic plexus injury. Proper identification and preservation of the hypogastric nerves is mandatory during nerve-sparing DIE surgery. We develop two methods to identify the hypogastric nerve within the USL DIE complex. (1) “Contralateral nerve traction test”: If we can clearly identify and isolate the hypogastric nerve on the more healthy side, by gentle pulling on this side hypogastric nerve, we can see the contralateral hypogastric nerve move on the other side. Thus we can have a good mapping of the course of hypogastric nerve within the DIE complex. (2) “Antegrade tracing from pre-sacral region”: If we move upward to the pre-sacral region, starting dissection from the virgin site, proximal part of hypogastric nerve can be easily identified. Antegrade tracing along the hypogastric nerve, un-roofing and bi-half the overlying DIE USL tissue, the whole course of hypogastric nerve can be safely traced and the nerve can be well-preserved. Conclusion Proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery is important. By this two simple methods and concepts (“contralateral nerve tract test” and “antegrade tracing”), we can minimize the risk of inadvertent nerve injury.

Outcome of everted end-to-end urethroplasty in traumatic bulbar and membranous urethra.

Introduction: Numerous options are available for the surgical management of urethral strictures. Everted End-to-end anastomosis is the utmost effective management for bulbar and membranous urethral strictures with a documented high success rate with low postoperative morbidity.&#x0D; Methodology: This study was conducted at department of Urology, Lahore General hospital, Lahore from May 2012 till May 2014. Total 30 patients were included in the study. Procedure was done by a single surgical team and Uroflowmetry and subjective evaluation was done on 2nd week, 1st month and 4th month and 12th month post operatively.&#x0D; Results: Mean age of patients was 24.43±12.39 years. Mean stricture length preoperatively was 1.83±0.63 cm. On follow up 50% of patients were in each grade whose subjective grading were 1 and 2 at 2 week post operatively. After 1-month post operatively 76.67% patients had Grade-1 and 6.67% patients had Grade-2. After 1 month follow up 63.34% patients presented with grade-1, 20% with Grade-2 and 6.67% presented with Grade-3. Only 80% of the patients at 4th month and 1-year post operatively presented with grade-1 subjective improvement. 10% of the patients had stricture recurrence at 1-month follow up and another 10% had recurrence at 4 months of follow up.&#x0D; Conclusion: Everted End-to-end urethroplasty is treatment of choice for short traumatic bulbar and membranous urethral strictures with a high success rate.&#x0D; Key Words: Urethral Strictures, Everted End-to-end Urethroplasty, Bulbar Urethra, Membranous Urethra

Surgery for high-risk locally advanced (pT3c) renal tumours: oncological outcomes and prognostic significance of a modified International Metastatic Renal Cell Cancer Database Consortium (IMDC) score.

To evaluate contemporary oncological outcomes and long-term survival in patients undergoing surgery for urological tumours involving the peridiaphragmatic inferior vena cava up to the level of the right atrium. To apply prognostic factors developed for metastatic renal cancer to patients with very-high-risk but apparently localized tumours, and develop a scoring system. A retrospective cohort study of 54 patients referred between December 2007 and April 2018 to a single surgical and oncological team was conducted. Electronic patient records were used to obtain peri-operative data and oncological follow-up. For operated patients lost to follow-up, survival data were obtained from primary care physicians. We used Kaplan-Meier curves to estimate overall survival (OS) and disease-free survival. For the subgroup undergoing curative surgery (n = 32) the prognostic value of a renal cancer score developed at Guy's Hospital using five of the six criteria in the International Metastatic Renal Cell Carcinoma Database Consortium prognostic model (one point for each of anaemia, neutrophilia, thrombophilia, hypercalcaemia and Karnofsky performance status <80), in order to be relevant for M0 disease, was assessed using the log-rank test. The median (interquartile range [IQR]) OS of the whole cohort was 29 (11-57) months. The median (IQR) survival of the curative subgroup (n = 32) was 32 (16-57) months, vs 11 (4-upper limit not reached) months for the cytoreductive subgroup (n = 13; P = 0.14). The median (IQR) follow-up time was 14 (1-65) months for patients alive at analysis. Disease-free survival in the curative subgroup was 10 (6-30) months. The median (IQR) OS by risk category for curative cases, as defined by the Guy's renal cancer score, was not reached in the favourable risk group (score = 0 points) because there were no patient deaths, 43 (30-61) months in the intermediate-risk group (score = 1 point), and 18 months (11-32) months in the poor-risk group (score ≥ 2 points; P = 0.005). A median survival of 29 months appears to justify this type of surgery. A prognostic model, the Guy's renal cancer score, using five readily available clinical measures, appears promising in patients with very-high-risk locally advanced tumours.

Technique and outcomes of 79 consecutive uniportal video-assisted sleeve lobectomies.

Uniportal video-assisted thoracic surgery (VATS) is well accepted by surgeons for anatomical major lung resections. However, large series evaluating the results, safety and efficacy of the technique for sleeve resections are still lacking. The aim of this study was to examine our experience with the use of uniportal VATS for sleeve resections. From September 2014 to January 2018, a total of 79 consecutive patients were offered uniportal VATS sleeve resection for centrally located tumours invading the orifice of the lobar bronchus or extending into the main stem bronchus by a single surgical team of the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. Perioperative data were collected and analysed. Survival data were collected via telephone calls. Sixty-six of the 79 patients had a diagnosis of non-small-cell lung cancer, 47 of whom had squamous cell carcinoma. Twenty-one of the group with non-small-cell carcinoma were already at an advanced stage (III, IV) when operated on. The mean number of lymph node stations dissected was 5.5 ± 0.97 (4-8) and that of lymph nodes harvested was 13.7 ± 3.7 (5-23). A right upper lobectomy was the most common and time-consuming procedure. There was 1 conversion to a thoracotomy due to bleeding. No anastomotic-related complications were noted. The mean length of stay was 5.14 ± 1.56 (2-11) days. The 1- and 2-year survival rates were 98% and 80%, respectively. Uniportal VATS sleeve resection is a safe and efficient procedure for the treatment of centrally located tumours otherwise requiring a pneumonectomy.

Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation.

A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (eDCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long-term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team. A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent eDCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation. Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow-up of 28.7 (range 6-114) months. At the most recent follow-up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103). Outcomes of powered eDCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long-term results suggest that mucosal flap preservation is not required to achieve successful outcomes with eDCR. 4 Laryngoscope, 130:12-17, 2020.

Repair of degenerative mitral regurgitation: An update.

The recent development of catheter-based therapies for structural valve disease, such as mitral-TAVI, MitraClip and left atrial appendage occlusion devices, makes a review of surgery for degenerative mitral valve disease timely. In this personal perspective we discuss the evolution of mitral valve repair, the core principles involved and the evidence base behind it through the lens of a single UK-based surgical team operating for a quarter century, illustrating the techniques, outcomes and some of the pitfalls of intervention.

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh-results from a general surgical unit.

Symptomatic ventral herniation is a common clinical presentation. The treatment, whether elective or as an emergency, can be difficult and a variety of surgical repairs are utilised. Intraperitoneal onlay mesh (IPOM) involves the placement of a reinforcing prosthesis, usually supported by primary closure of the defect. Intra-abdominal adhesions have been highlighted as a potential complication in utilising this form of mesh placement. Several methods of laparoscopic mesh placement outside of the peritoneal cavity are gaining prominence as potential alternatives to IPOM. This study reviews our experience with IPOM in the repair of ventral hernia by a single surgical team. A prospectively maintained electronic database of all laparoscopic ventral hernia repair (LVHR) performed within the study period was analysed and reported. Follow-up questionnaires were sent to patients to follow long-term outcomes. One hundred eight patients underwent LVHR over a 7-year period. Demographics demonstrated an obese patient group (BMI 30.89 ± 4.9kg/m2), with a variety of hernia sizes and morphologies. Hernia recurrence was found in two patients (1.8%). Twenty-nine (26.8%) patients suffered a complication, but only eight (7.4%) of those required intervention beyond pharmacotherapy. Two patients required mesh explantation. IPOM for the general surgeon is a relatively safe and effective method of repairing ventral hernias, with a low recurrence rate.

The Predictive Role of Intraoperative Visual Evoked Potentials in Visual Improvement After Endoscopic Pituitary Tumor Resection in Large and Complex Tumors: Description and Validation of a Method

With the advent of extensive endoscopic approaches for pituitary tumors, there has also been an increase in surgery for larger and more complex tumors. Intraoperative manipulation during endoscopic resection of sellar tumors poses potential risk in postoperative visual function in this tumor population. This study proposes a method of accurate intraoperative monitoring of visual evoked potentials (VEPs) and its role in predicting visual function outcomes. Intraoperative VEPs were monitored for 42 resections from a single surgical team, with average tumor size of 2.84 cm. Changes in VEP amplitude and latency in excess of 50% were considered significant. Preoperative and postoperative visual information was obtained from ophthalmology and hospital records, along with patient demographics, comorbidities, and tumor characteristics. Patients were stratified as experiencing deteriorations in VEPs that did not restore to baseline (n= 4), deteriorations in VEPs that did restore to baseline (n= 6), no change in VEPs (n= 31), and improvement in VEPs (n=1). Correlation between VEP changes and postoperative visual fields was measured through univariate ordered logistic regression. Improved intraoperative VEP measurements were associated with odds ratio (OR) of visual field improvement of 3.15 (95% confidence interval, 1.15-8.59). Specifically, changes in VEP amplitude were positively associated with visual field improvement with OR of 4.35 (OR, 1.29-14.7). No association was observed between VEPs and other patient or tumor characteristics. Changes in VEP amplitude during endoscopic sellar tumor resection correlate with postoperative visual function. Intraoperative VEP monitoring can serve an important role in preventing postoperative visual field loss.

Surgical techniques and short-term outcomes of transvesical robot assisted radical prostatectomy

Objective To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP). Methods From April 2018 to August 2018, 10 patients underwent TvRARP performed by a single surgical team were retrospectively reviewed. Preoperative data of patients [aged (58.6±9.4) years, BMI (26.5±3.1) kg/m2, tPSA (19.5±4.1) ng/ml, biopsy Gleason score 6(6-7), prostate volume (33.4±15.8)ml and IIEF-5 score 12(10-16)] were collected. Preoperative study revealed 8 cases of cT1c, 1 case of cT2a and 1 case of cT2b. All patients were continent preoperatively. During the surgical procedure, the bladder was opened, and a circumferential incision was then made around the internal urethral orifice. Initially, posterior dissection of bilateral vas deferens and seminal vesicles was performed, followed by posterior dissection towards apex. Lateral dissection of neurovascular bundles was performed before anterior dissection towards apex. The exposed urethra was transected and specimen was removed. Vesicourethral anastomosis and closure of bladder was performed in a standard way. Results All 10 cases were successfully performed robotically without conversion, transfusion or other major intraoperative or postoperative complications. Postoperative pathology confirmed 6 cases of pT2a , 3 cases of pT2b and 1 case of pT2c [median Gleason score 6(6-7)]. One case was reported positive surgical margin. Operative time was (140.5±35.5) mins. Estimated blood loss was (65.5±35.5) ml. Urethral catheter was removed at 7 days postoperatively. Nine patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 1 patient returned to full continence at 2 weeks postoperatively. During a mean follow-up of 3 months (2-4 months), no biochemical recurrence was detected (tPSA 0.05). Conclusions Transvesical approach is a valid alternative of RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined by long term follow-up. Key words: Radical prostatectomy; Robot; Transvesical approach; Localized prostate cancer

Protein-Calorie Malnutrition Requiring Revisional Surgery after One-Anastomosis-Mini-Gastric Bypass (OAGB-MGB): Case Series from the Tehran Obesity Treatment Study (TOTS).

One-anastomosis-mini-gastric bypass (OAGB-MGB) is the second most popular gastric bypass procedure with remarkable weight loss results and comorbidity resolution rates. However, some concerns remain regarding its postoperative complications, including protein-calorie malnutrition (PCM). We hereby report our experience with patients who returned with severe PCM after OAGB-MGB. Patients with severe obesity presenting to our referral bariatric center underwent OAGB-MGB surgery using a 200-cm biliopancreatic limb (BPL) by a single surgical team at three university hospitals from March 2014 to February 2016. From 189 patients undergoing OAGB-MGB, seven patients (3.7%), all female, with a mean age of 46.4 ± 8.2years and initial body mass index (BMI) of 44.2 ± 4.7kg/m2, were readmitted for signs of PCM. Lower extremity edema, fatigue, excessive weight loss, hypoalbuminemia, anemia, and pancytopenia were the presenting symptoms and lab findings. Revisional surgery was performed at a mean 19 ± 9.7months after OAGB-MGB after failure of supportive measures. The mean BMI at the time of revision was 22.5 ± 2.6kg/m2 with an excess weight loss of 109.2 ± 22.1%. After revisional surgery, one patient developed profound liver failure and expired. Another patient developed severe steatohepatitis but ultimately recovered. In the remaining five, edema and fatigue completely resolved at 1month and hypoalbuminemia and anemia normalized at 2months. A one-fits-all BPL length of 200cm is increasingly being questioned as it may result in an inadequate absorptive area and PCM in a subset of patients with shorter total bowel lengths, potentially placing them in danger and depriving them of bariatric surgery benefits.

Systemic Laparoscopic Para-Aortic Lymphadenectomy to the Left Renal Vein.

Background:No large-scale clinical study has been done to show the standard surgical boundary and efficacy of laparoscopic para-aortic lymphadenectomy (LPAL).Objectives:Therfore, this study aimed to evaluate the feasibility, efficacy, and standard surgical boundary of LPAL performed up to the left renal vein level in gynecological malignancies.Methods:Medical records of 333 patients were retrospectively reviewed. All cases had gynecologic malignancies and had an operation including LPAL by a single surgical team between November 2003 and May 2018.Results:Three hundred twenty-six patients underwent LPAL as part of their staging, restaging, or debulking surgery. Seven patients with isolated para-aortic lymph node recurrence underwent a repeat LPAL. The median age and body mass index were 54 years (range, 28–81 years) and 26.0 kg/m2 (range, 20.3–37.2 kg/m2), respectively. The median operating time was 60 minutes (range, 24–135 minutes), and the median number of harvested para-aortic lymph nodes was 12 (range, 6–49). There were 11 cases of complications: 5 of major vessel injuries (3 inferior vena cava, 1 aorta, and 1 common iliac vein), 2 lymphocysts, 2 cases of chylous ascites, a cisterna chyli rupture, and 1 case of ureteric injury. There were 2 conversions to laparotomy: 1 left common iliac vein laceration that needed to be repaired and removal of an enlarged para-aortic lymph node completely.Conclusion:It is feasible and efficient to perform LPAL to the left renal vein level for women with gynecologic malignancies by well-trained gynecologic oncology surgeons according to our suggested standard surgical boundary.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience.

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Cervical Lymph Node Dissection for Papillary Thyroid Cancers: A Decade Experience of a Single Surgical Team.

Background: All patients undergoing thyroid operations should be subjected to preoperative neck ultrasound (US) followed by fine needle aspiration cytology (FNAC) of suspicious lesions. In Western countries, thyroid surgeons routinely perform neck ultrasound. The role of prophylactic central neck dissection (PCND) remains a topic of debate. For treatment of papillary thyroid carcinoma (PTC), in 2014 we introduced two new adjuncts: PCND based on criteria of the European Society of Endocrine Surgeons (ESES) consensus group and surgeon-performed US (S-US). Methods: In order to better understand the role of these two adjuncts in our shift of strategy we aimed to evaluate the outcomes of our patients in two successive 5-year time periods based on a retrospective analysis of our prospectively maintained database (total of 286 patients were included in this study). Results: The two groups were similar regarding epidemiological and clinical data. FNAC was done in only 21.66% of all PTC cases. PTC diagnosis was done in the majority of suspicious cases by FS. S-US guided the selective lateral node dissections (LND), leading to more lymph node metastases detections and it also surpassed endocrinologist performed US (E-US) in terms of PPV. PCND rate of complications was significantly higher due only to transient hypoparathyroidism. Conclusions: Preoperative surgeon-performed ultrasonography is a useful tool in the arsenal of PTC treatment. The systematic preoperative FNAC diagnosis and intraoperative frozen sections in uncertain cases are mandatory. PCND is a safe method of treatment and staging in PTC.