Steep Trendelenburg Research Articles

Robot-assisted laparoscopic retroperitoneal lymph node dissection in testicular cancer using a single-position supine approach: A case report and literature review

Abstract This case study demonstrates a single-position supine approach for robotic retroperitoneal lymph node dissection for the treatment of nonseminomatous germ cell tumors and residual masses after chemotherapy. We performed a bilateral robotic retroperitoneal lymph node dissection in a 33-year-old man with nonseminomatous germ cell tumors and residual postchemotherapy masses. For this approach, the patient was placed in a steep Trendelenburg position, and a 5-port transperitoneal technique was used, with the robot docked so that the arms were oriented cephalad. This approach allowed simultaneous access to both sides of the retroperitoneum, thereby eliminating the need for bilateral lymphadenectomy and patient repositioning. Bilateral R-RPLDN was performed using a single-position supine approach. This versatile approach offers a less invasive, more efficient, and safer solution for removing residual postchemotherapy testicular cancer masses.

Perioperative optic nerve sheath diameter variations in patients with end-stage renal failure undergoing robotic-assisted kidney transplant: a prospective observational study.

Patients with chronic kidney disease (CKD) who undergo hemodialysis are predisposed to interstitial cerebral edema. Robotic-assisted laparoscopic surgery can increase optic nerve sheath diameter (ONSD) and intracranial pressure. The impact of robotic-assisted kidney transplant (RAKT) on ONSD is complicated by the presence of CKD, the administration of furosemide and mannitol, and the manipulation of hemodynamics. We examined ONSD variations in patients undergoing RAKT over a 1-year period at our institution. Furthermore, we attempted to identify any perioperative hemodynamic factors influencing these changes. This prospective study included 20 patients undergoing RAKT. ONSD, heart rate, central venous pressure, systolic blood pressure, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were measured following intubation (T1), after assuming the steep Trendelenburg position (T2), 1 hour after docking (T3), upon reperfusion (T4), after transition to the supine position (T5), and 3 hours postextubation (T6). Repeated measures analysis of variance with post hoc Bonferroni correction was employed to compare variables at each time point. Pearson correlation analysis was utilized to assess relationships between variables. P-values ≤0.05 were considered to indicate statistical significance. ONSD (in mm) increased from T1 (3.60±0.44) to T3 (4.06±0.45, P=0.002) and T4 (3.99±0.62, P=0.046), before falling to its lowest value at T6 (3.42±0.64, P=0.002). Pearson correlation analysis revealed significant correlations (P<0.05) between changes in ONSD at T3 and both DBP (r=0.637) and MAP (r=0.522). During RAKT with open ureteric anastomosis, ONSD initially increased, then decreased following reperfusion. DBP and MAP displayed positive correlations with ONSD changes at T3.

The Effect of Intermittent Pneumatic Compression on Hemodynamics and Regional Cerebral Oxygen Saturation in Laparoscopic Bariatric Surgery with Mild Hypercapnia in the Steep Reverse Trendelenburg Position.

Obesity negatively affects hemodynamics and cerebral physiology. We investigated the effect of the utilization of an intermittent pneumatic compression (IPC) device on hemodynamics and cerebral physiology in patients undergoing laparoscopic bariatric surgery under general anesthesia with lung-protective ventilation. Sixty-four patients (body mass index > 30 kg/m2) were randomly assigned to groups that received an IPC device (IPC group, n = 32) and did not (control group, n = 32). The mean arterial pressure (MAP), heart rate (HR), need for vasopressors, cerebral oxygen saturation (rSO2), and cerebral desaturation events were recorded. The incidence of intraoperative hypotension was not significantly different between groups (p = 0.153). Changes in MAP and HR over time were similar between groups (p = 0.196 and p = 0.705, respectively). The incidence of intraoperative cerebral desaturation was not significantly different between groups (p = 0.488). Changes in rSO2 over time were similar between the two groups (p = 0.190) during pneumoperitoneum. Applying IPC to patients with obesity in the steep reverse Trendelenburg position may not improve hemodynamic parameters, vasopressor requirements, or rSO2 values during pneumoperitoneum under lung-protective ventilation. During laparoscopic bariatric surgery, IPC alone has limitations in improving hemodynamics and cerebral physiology.

Association Between Acute Kidney Injury and the Trendelenburg Position Angle During Robot-assisted Radical Prostatectomy.

Robot-assisted radical prostatectomy (RARP) has been widely adopted as the standard treatment for localized prostate cancer. RARP is safer and results in better oncological control than conventional open total prostatectomy. However, it has also been reported that acute kidney injury (AKI) can be caused by the use of carbon dioxide pneumoperitoneum and a steep Trendelenburg position. We investigated the incidence of AKI after RARP and its relationship with the Trendelenburg position angle. Seventy-seven patients underwent RARP at our institution. They were divided into two groups: Those in which a Trendelenburg position with the head down at 20 degrees was employed (group A) and those in which a Trendelenburg position with the head down at 25 degrees was used (group B). To detect AKI, the serum creatinine concentration was measured at the following four points: Prior to surgery, on postoperative day 0 (immediately after RARP), and on postoperative days 1 and 6 after RARP. The incidence of AKI on POD 0 was lower in group B than in group A (p=0.0408). On POD 6, the renal function of all patients had improved to preoperative levels. Hypertension was a predictor of the incidence of AKI immediately after RARP. Although there was a significant Trendelenburg position angle-dependent difference in the incidence of AKI immediately after RARP, it was temporary. Hypertension is a predictor of AKI immediately after RARP. It is recommended that a 25-degree Trendelenburg position angle should be employed during RARP.

Retrospectif Analysing of Anesthesia Manegement in Robotic Assisted Radical Prostatectomy Cases

Aim: In our study, we aimed to investigate anesthesia management, hemodynamic changes and complications that may ocur due to steep trendelenburg, pneumoperitoneum and sugery in RARP patients operated in A.U.T.F, and to evaluate our initial results.&#x0D; Methods: Patients who underwent RARP operation with the diagnosis of prostate adenocarcinoma by the Urology Clinic at Akdeniz University Faculty of Medicine between January 2015 and February 2018 were evaluated retrospectively. Patient’s demographic data, intraoperative hemodynamic and respiratory data, postoperative transfer sites, extubation times, post-extubation blood gas values, complications and discharge times were recorded. Obtained data were analyzed with IBM SPSS® 23.0 program.&#x0D; Results: We found that mean age of the 131 patients included study was 62 years, and mean BMI was 27,6 kg/m2. Also we found that 47 of patients were ASA-I, 69 of patients were ASA-II and 15 of patients were ASA-III. After general evaluation, it was seen that HR, SBP, DBP and MAP decreased significantly in intraoperative period in all patients. There was also a significant decrease in pH and increase in pCO2 in patients due to pneumoperitoneum. In our study, we found thah the most common postoperative complication was nause and vomiting, and the second common was anastomotic leakage. However, none of our patients had a permanent complication. &#x0D; Conclusion: In order to manage anesthesia in RARP, it is necessary to know the physiologic effects of trendelenburg position and pneumoperitoneum on the systems and physiological changes in old age.

Mesial temporal atrophy in preoperative MRI rather than steep Trendelenburg position is associated with postoperative delirium in patients undergoing a major urologic surgery.

To investigate whether steep Trendelenburg in a major urologic surgery is associated with postoperative delirium, and to examine other potential clinical and radiologic factors predictive of postoperative delirium. 182 patients who received a major urologic surgery and underwent a 3.0-T brain MRI scan within 1year prior to the date of surgery were retrospectively enrolled. Preoperative brain MRIs were used to analyze features related to small vessel disease burden and mesial temporal atrophy. Presence of a significant mesial temporal atrophy was defined as Scheltens' scale ≥ 2. Patients' clinico-demographic data and MRI features were used to identify significant predictors of postoperative delirium using the logistic regression analysis. Independent predictors found significant in the univariate analysis were further evaluated in the multivariate analysis. Incidence of postoperative delirium was 6.0%. Patients with postoperative delirium had lower body mass index (21.3 vs. 25.0kg/m2, P = 0.003), prolonged duration of anesthesia (362.7 vs. 224.7min, P < 0.001) and surgery (302.2 vs. 174.5min, P < 0.001), and had more significant mesial temporal atrophy (64% vs. 30%, P = 0.046). In the univariate analysis, female sex, type of surgery (radical prostatectomy over cystectomy), prolonged duration of anesthesia (≥ 6h), and presence of a significant mesial temporal atrophy were significant predictors (all P-values < 0.050), but only the presence of significant mesial temporal atrophy was significant in the multivariate analysis [odds ratio (OR), 3.69; 95% CI 0.99-13.75; P = 0.046]. Steep Trendelenburg was not associated with postoperative delirium. Significant mesial temporal atrophy (Scheltens' scale ≥ 2) in preoperative brain MRI was predictive of postoperative delirium. Not applicable.

Physiological Responses in Relation to Robotic Prostatectomy

Learning physiological responses through clinical application provides a meaningful experience that engraves itself in one’s mind forever. Robotic prostatectomy requires a patient to be positioned in a steep Trendelenburg, and this is associated with many physiological responses that involve the cardiovascular, respiratory, and central nervous system. Understanding the physiological responses during the robotic prostatectomy provides vital intraoperative monitoring and ensures the patient’s safety.

Technical Considerations and Approach to Redo Foregut Surgery.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redohiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissectionto free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Role of lung ultrasonography for diagnosing atelectasis in robotic pelvic surgeries

Patients undergoing robotic pelvic surgery were included in prospective observational study, they are at increased risk of atelectasis and postoperative pulmonary complications.Lung ultrasonography in basal six zones and arterial gas analysis was performed as baseline after induction of GA and on de-docking robotic arms to detect incidence and severity of atelectasis and its effect on arterial oxygenation.Total fifty patients were recruited in the study with age 61.88 ± 8.49 years, BMI 25.97±4.03, intraoperative with steep trendelenburg position, average duration of docking was 155.32 ± 47.44 minutes, VCV provided to 29 and PCV to 21 patients. [Lung aeration score 0] was noted for all patients in Right anterior basal –Zone I, 50-60% of patients developed mild atelectasis [Lung Aeration score1] in Posterior basal zones III and VI. Total 10% patients developed moderate atelectasis [Lung Aeration score 2] and 4% developed severe atelectasis [Lung Aeration score 3] in zones III and VI. The incidence and severity of atelectasis was not affected by duration of robotic arms docking and mode of ventilation. For both VCV and PCV group statistically significant (p&amp;#62;0.05) decrease in Arterial Oxygen Pressure (Pao2) and Alveolar-arterial (A-a)o gradient difference was detected after completion of robotic surgery compared to baselines values. Atelectasis was detected in 60% patients in bilateral basal posterior zones in patients undergoing robotic pelvic surgeries causing statistically significant decrease in PaO2 compared to baseline values. Early detection of atelectasis by Lung Ultrasonography in the OR and applying optimal PEEP is recommended.

Features of Mechanical Lung Ventilation During Robot-Assisted Radical Prostatectomy in Patients with Different Body Mass Index

The aim of the study. To evaluate effects of carboxyperitoneum and steep Trendenburg position on respiratory biomechanics and gas exchange indicators in patients with different body mass index (BMI) during robotic-assisted radical prostatectomy (RRP). To develop an algorithm for choosing the optimal mechanical lung ventilation (MLV) regimen. Materials and methods. The study included 141 patients with verified prostate cancer who were candidates for RPR. Participants were divided into 2 groups based on BMI: group I included 88 patients with BMI30 kg/m2, group II — 53 patients with BMI30 kg/m2. Indicators of respiratory biomechanics and gas exchange during ventilation in various modes (Volume Controlled Ventilation (VCV), Pressure Controlled Ventilation (PCV), Pressure Controlled– Inverse Ratio Ventilation (PC-IRV) were analyzed in each group at 5 consecutive stages of the procedure.Results. The key parameters evidencing the effectiveness and safety of MLV during RRP procedure did not vary significantly under various ventilation regimens in the group of patients with a BMI30 kg/m2. Whilst in obese patients the use of VCV mode resulted in a significant increase of airway peak pressure (Ppeak) already at the stage of placing them into a steep Trendelenburg position (35°), thus endangering with the development of ventilator-induced lung injury. Increased Ppeak was also accompanied by the drop in oxygen saturation and significantly lower SpO₂ values, starting from the stage of applying carboxyperitoneum and until the end of surgical intervention.Conclusion. In non-obese patients, there’s no particular ventilator regimen that is crucial for achieving the safety and effectiveness of RRP anesthesia management, all regimens can be used. In patients with BMI30 kg/m2 PCV regimen and PC-IRV with inhalation/exhalation ratio of 1.5:1 can be considered as the optimal strategy for MLV during anesthesia for RRP surgery.

Perioperative lung function following flow controlled ventilation for robot-assisted prostatectomies in steep trendelenburg position: an observational study

BackgroundSteep Trendelenburg position combined with capnoperitoneum can lead to pulmonary complications and prolonged affection of postoperative lung function. Changes in pulmonary function occur independent of different modes of ventilation and levels of positive end-expiratory pressure (PEEP). The effect of flow-controlled ventilation (FCV) has not been evaluated yet. We perioperatively measured spirometric lung function parameters in patients undergoing robot-assisted prostatectomy under FCV. Our primary hypothesis was that there is no significant difference in the ratio of the maximal mid expiratory and inspiratory flow (MEF50/MIF50) after surgery.MethodsIn 20 patients, spirometric measurements were obtained preoperatively, 40, 120, and 240 min and 1 and 5 days postoperatively. We measured MEF50/MIF50, vital capacity (VC), forced expiratory volume in 1 s (FEV1), and intraoperative ventilation parameters.ResultsMEF50/MIF50 ratio increased from 0.92 (CI 0.73–1.11) to 1.38 (CI 1.01–1.75, p < 0.0001) and returned to baseline within 24 h, while VC and FEV1 decreased postoperatively with a second nadir at 24 h and only normalized by the fifth day (p < 0.0001). Compared to patients with PCV, postoperative lung function changes similarly.ConclusionFlow-controlled ventilation led to changes in lung function similar to those observed with pressure-controlled ventilation. While the ratio of MEF50/MIF50 normalized within 24 h, VC and FEV1 recovered within 5 days after surgery.

Lung ultrasonography for detection of atelectasis in adults undergoing robot assisted laparoscopic pelvic surgeries

Introduction: Robot-assisted laparoscopic pelvic surgeries are minimally invasive techniques that require the patient to be placed in the steep Trendelenburg position. Pneumoperitoneum further increases the risk of postoperative pulmonary complications. We used lung ultrasound score (LUSS) to detect post-operative atelectasis in this subset of patients.&#x0D; Methodology: Patients aged 18 to 70 y with ASA physical status I/II undergoing robot assisted pelvic surgeries in steep Trendelenburg position were enrolled. Patients were mechanically ventilated with 50% oxygen in air with a tidal volume of 6 to 8 ml/kg in volume control mode to maintain an end tidal carbon dioxide at 35−45 mmHg with positive end-expiratory pressure (PEEP) of 5 cmH2O. Ultrasonographic assessment was done; before induction (A), after extubation (F), 12 h (G) and 24 h after surgery (H) by dividing chest into 12 regions.&#x0D; Results: A total of 1152 cine-loops acquired during the study period in 32 patients were analyzed. Incidence of postoperative atelectasis was 87.5% and each lung ultrasound examination required 12.35 ± 4.68 min. Statistically significant fall in PaO2 was recorded at extubation from baseline and intra-operative values (P &lt; 0.0001). Statistically significant difference was established between change in baseline and post-extubation LUSS to the total volume of fluid given (P = 0.002).&#x0D; Conclusion: A high incidence (87.5%) of atelectasis in adults after robot assisted laparoscopic pelvic surgeries was detected using lung ultrasound score. Lung oxygenation decreased significantly after steep Trendelenburg position and extubation. The observed statistical difference in total IV fluids administered between patient subgroups who showed increased ultrasound signs of lung edema from the A period to the F period, although suggestive of association, is no evidence of causation.&#x0D; Abbreviations: ARISCOT- Assess Respiratory Risk in Surgical patients in Catalonia; LUS- Lung Ultrasound; LUSS- Lung Ultrasound Score; OR- Operating room; PEEP- Positive End-Expiratory Pressure&#x0D; Key words: LUSS; Lung ultrasound score; Pneumoperitoneum; Robotic Surgery; Ultrasonography&#x0D; Citation: Sethi S, Kathuria R, Samra T, Saini V, Toshkhani D, Kushal P. Lung ultrasonography for detection of atelectasis in adults undergoing robot assisted laparoscopic pelvic surgeries. Anaesth. pain intensive care 2023;27(4):573−578; DOI: 10.35975/apic.v27i4.1503&#x0D; Received: October 28, 2021; Reviewed: June 06, 2022; Accepted: September 17, 2022

Semisitting position for cerebello-pontine angle surgery: Analysis of complications and how to avoid it

ObjectiveTo analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery. MethodsRetrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery. ResultsFifty patients were operated on. Eleven (22%) presented VAE (mean duration 8±4.5min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR=4.58, p=0.001. NICU was higher in patients with VAE (5.5±1.06 vs. 1.9±0.20 days, p=0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. ConclusionsThe semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.

Spontaneous pneumothorax during vaginal hysterectomy in lithotomy with steep Trendelenburg position—a case report

BackgroundPneumothorax associated with a steep head-down position in vaginal hysterectomy surgery is rare but can cause life-threatening complications.Case presentationWe report a case of a female patient with no obvious lung pathology who suffered intraoperative pneumothorax associated with prolonged steep Trendelenburg position. To the best of our knowledge, this is the first well-documented case of this association. A 53-year-old female, diagnosed as a case of recurrent umbilical hernia with cystocele and rectocele was planned for vaginal hysterectomy with anterior perineorrhaphy and posterior colpoperineorrhaphy along with open mesh repair for umbilical hernia under general anaesthesia. Approximately 90 min after the steep Trendelenburg position, the peak inspiratory pressure increased, while the oxygen saturation decreased. The airway pressures remained continuously on the higher side whole throughout the surgery despite an interrupted propped-up position in between. The patient could not be extubated and shifted to the intensive care unit (ICU) where ultrasonography (USG) of the lung and chest x-ray showed signs of pneumothorax. Intercostal tube drainage (ICTD) was placed, and the patient improved dramatically. It was suspected that a steep head-down position for a prolonged period led to persistently raised airway pressures and the subsequent development of pneumothorax.ConclusionsPneumothorax can develop in rare circumstances even if airway pressures are under the safety range. So, careful monitoring and immediate treatment are necessary to prevent the condition from worsening and anaesthesiologists must be aware of such potential danger.

Posición semisentada en cirugía del ángulo pontocerebeloso: análisis de sus complicaciones y cómo evitarlas

ObjectiveTo analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery. MethodsRetrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery. ResultsFifty patients were operated on. Eleven (22%) presented VAE (mean duration 8 ± 4.5 min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR = 4.58, P = 0.001. NICU was higher in patients with VAE (5.5 ± 1.06 vs. 1.9 ± 0.20 days, P = 0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. ConclusionsThe semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

ABSTRACT The original technique for mesh midurethral sling, which utilized a retropubic approach for sling placement, also recognized a risk of simultaneous iatrogenic bladder injury. While synthetic mesh midurethral slings have the criterion standard for SUI treatment, there is still no available technique that entirely eliminates the risk of bladder injury at the time of implantation. The retropubic approach holds a 0.7% to 34% rate of bladder injury. Some providers still opt for the transobturator approach because of a perceived decreased risk of intraoperative bladder perforation. This article describes the “C-clamp technique,” a method directly addressing the perceived key causes of bladder injury via the retropubic approach. This study aimed to determine bladder injury rates upon surgical implantation of retropubic synthetic mesh midurethral sling by 1 provider using the C-clamp technique. The article provides step-by-step instructions for this technique, as well as a link to a video (https://links.lww.com/FPMRS/A362). Briefly, the technique involves use of a deflecting catheter guide in steep Trendelenburg, “clamping” the pubis with the operator's nondominant hand to decrease the retropubic distance, and using the nondominant thumb on the inner curve of the trocar to guide the trocar passage toward the nondominant finger tips and suprapubic exit through the skin. This retrospective review identified 201 bottom-up retropubic synthetic mesh midurethral slings placed using the C-clamp technique between April 2012 and June 2022. General data collected included average age (51 years), average weight (46–139 kg), average body mass index (BMI, 15–57 kg/m2), and a range of prior surgical procedures and concomitant procedures. Approximately 15% of patients had a history of prior retropubic urethropexy or some form of midurethral sling. There were no lower urinary tract injuries in the entire cohort. Strengths of this study include its description of the C-clamp technique, the extremes and range of data points included within the study, and the 10-year range of the study. Limitations include its retrospective nature, the single surgeon provider, the vast majority of slings used produced by 1 manufacturer, and limited comprehensive data collection. Using data from 201 consecutive bottom-up synthetic mesh midurethral sling outcomes during a 10-year span, the authors argue that this technique addresses key anatomic issues contributing to bladder and urethral injury during placement of such slings, with a promising ability to eliminate bladder and urethral injury. Favorable data in a larger number of patients and by multiple providers could provide further support to this technique and support retropubic sling as a preferred method of midurethral sling.

Modes of mechanical ventilation and ultrasound scan technique for evaluating the optic nerve sheath diameter in patients undergoing surgery in the steep Trendelenburg position.

Modes of mechanical ventilation and ultrasound scan technique for evaluating the optic nerve sheath diameter in patients undergoing surgery in the steep Trendelenburg position.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update.

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

The use of a modified rescue cervical cerclage in a diamniotic dichorionic twin pregnancy that had cervical dilatation

AbstractObjectiveWe describe the successful utilization of a modified rescue cerclage in a 32‐year‐old G4 P1213 woman of Afro‐Caribbean descent with a Diamniotic Dichorionic twin gestation who presented at 20 weeks and 2 days for a routine anomaly scan and was found to have a dilated (1.7 cm) and short (0.49 cm) cervix.DesignA standard prophylactic cervical cerclage was done at 12 weeks' gestation using Mersilene™ tape. For the rescue cerclage, the client was placed in a steep Trendelenburg position, with back filling of the bladder. The cervix was grasped with ring forceps, and an inflated foley balloon catheter was introduced into the cervical opening to aid in reduction of membranes. In addition to the initial cerclage, two 1‐ Prolene™ sutures were inserted distally to the tape and a second Mersilene™ tape was inserted proximally at the vesicocervical junction (reinforcement cerclages). The first Prolene™ was to provide additional structural support to prevent prolapse of the membrane. The second Prolene™ was used to close the external cervical or to minimize the risk of an ascending infection. The procedure was uneventful and postoperatively she was treated with antibiotics, vaginal micronized progesterone and venous thromboembolism prophylaxis. The membranes remained intact.ResultThe twins were successfully delivered by a scheduled repeat caesarean section at 36 weeks with Twin 1 Apgar scores of 9 and 9 at 1 and 5 min, respectively, and Twin 2 Apgar scores of 8 and 10, respectively.ConclusionIn the context of a challenging obstetric history as in this case, a more aggressive approach inclusive of reinforcement cerclage may be considered. The successful outcomes in this case further reiterates the need for larger clinical trials with pregnant individuals with larger cervical dilations at entry.

V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP

You have accessJournal of UrologyCME1 Apr 2023V01-04 SINGLE-PORT ROBOTIC EXTRAPERITONEAL RIGHT URETERAL REIMPLANTATION WITH BOARI FLAP Melissa Moran, Alain Kaldany, Krishna Doppalapudi, Arnav Srivastava, and Sammy Elsamra Melissa MoranMelissa Moran More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Krishna DoppalapudiKrishna Doppalapudi More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , and Sammy ElsamraSammy Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple abdominal surgeries often harbor hostile abdomens with significant bowel adhesions. It is thus difficult to obtain safe transperitoneal access when placing robotic trocars. An extraperitoneal approach, in contrast, allows for safe entry into the abdomen. In the case of a mid to distal ureteral stricture requiring extraperitoneal Boari flap ureteral reimplantation, the conventional multiport approach would be suboptimal as arm spacing would be insufficient. Here we demonstrate our surgical technique and the feasibility of a single port (SP) extraperitoneal Boari flap ureteral reimplantation. METHODS: A 70-year-old female with a history of rectal cancer treated with multiple abdominal surgeries and chemoradiation was diagnosed with a distal right ureteral stricture. She was offered SP robotic ureteral reimplantation for definitive management. The patient was positioned in steep Trendelenburg with a left-sided tilt. A 4 centimeter (cm) incision was created over the right lateral aspect of the abdomen 8 cm above the anterior superior iliac spine, and the retroperitoneal space was entered. The SP access port was placed and the robot was docked. The ureter was identified crossing the iliac vessels and was dissected proximally and distally. Once scar tissue was encountered, the ureter was transected. The bladder was mobilized and the medial umbilical ligament was cut. The distance from the ureter to the bladder was measured, and a Boari flap of this length was created. The posterior ureter was then spatulated and a Boari flap anastomosis was performed. The bladder was closed in a Heineke-Mikulicz fashion and a double-J ureteral stent was placed in the right ureter. The bladder was distended to ensure a watertight closure. A drain was placed and the Foley catheter was exchanged. RESULTS: The operative time was roughly three hours, with 50 milliliters of estimated blood loss. On post-operative day one, the drain was removed and patient was discharged home. Imaging two weeks later showed improved hydronephrosis with no urine extravasation, and the Foley catheter was removed. The ureteral stent was removed at four weeks post-operatively. Ultrasound and renal scan three months later demonstrated improved hydronephrosis with preserved renal function and no evidence of obstruction. CONCLUSIONS: To our knowledge, this is the first video demonstrating an SP extraperitoneal Boari flap ureteral reimplantation. This approach is feasible and allows a surgeon to safely and effectively perform a primarily retroperitoneal procedure without entering a hostile abdomen. 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 Melissa Moran More articles by this author Alain Kaldany More articles by this author Krishna Doppalapudi More articles by this author Arnav Srivastava More articles by this author Sammy Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...