UroToday – Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy

Source Urotoday.com
I found an abstract about a way to manage urinary ascites that can rarely happen after dvP.

Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.

Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.

In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.

I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.

While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foley in away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.

Median Lobe in Robot-Assisted Radical Prostatectomy: Evaluation and Management

UroToday –

The surgical margins were similar between the two groups. No significant difference was found in the postoperative urinary bother score or the interval to social or perfect continence between the two groups.

The results of this study have shown that the presence of a median lobe does not alter the outcomes in patients who undergo robot-assisted prostatectomy.

The median lobe can be a scary finding for the novice robotic surgeon. My team at NBI has developed several techniques to handle median lobes while preserving as much bladder as possible. Below is a video showing one of our techniques:

I have changed by preoperative management to include a cystoscopy about 1 year ago on all patients to assess for prostate shape. I can now predict these in all patients.

I am a little surprised that these patients did not have differences except more needed bladder neck repairs. I think these patients are more likely to have bladder symptoms since most have obstruction and over active bladders to start with. In my series, they usually get their catheters out in 5 days instead of 3, and I warn them of expecting more urinary problems in the short term than others.

Effect on prostate size on prostatectomy recovery

clipped from www.medwire-news.md

“Prostate size has no effect on continence or biochemical recurrence at 1 year after laparoscopic radical prostatectomy, but affects intra-operative blood loss, potency and surgical margins,” Aron et al write in the BJU International.

blog it

The study points out what most people are concluding in regards to positive margins. Smaller prostate tend to have higher rates of positive margins. The results show that at 1 year the continence is similar, but the short term recovery of urinary function is not addressed. I think men with larger prostates take longer to regain urinary control.

Catheter withdrawal and suturing times of connection during robotic prostatectomy

UroToday – WCE 2007 – Single Knot Anastomosis (SKA) For Laparoscopic Radical Prostatectomy: An International Multicenter Outcome Survey of 5235 Cases

They have shown that the time to complete the anastomosis for the expert, second generation, and trainee surgeons were 16, 23, and 30 minutes respectively. Additional stitches were necessary only in 1.1%. The anastomosis was water tight in 94.2%.
Early leakage requiring prolonged catheter drainage occurred 6.8% of laparoscopic cases and 0% in the robotic assisted cases. Mean catheter time was 7.1 days. The bladder neck contracture rate was 0.8% at 12 months and the rate of acute urinary retention was 0.5%.

Dr. van Velthoven deserves credit dor being the first to devise a simpler, likely better way to make the bladder to urethra connection. Most surgeons, including myself, use this technique.

This large series shows the average time for a connection is 16 minutes and the average catheter is kept in for 1 week.

Some surgeons catheter times are much faster. I have watched Dr Patel and Dr Tewari perform the connection in well under 10 minutes, probably about 5.

My main work currently is trying to reduce the catheter time to as a few days as possible. I think with robotics we can cut down the catheter time to 3 days at least.

Sex After Robotic Prostatectomy: Penile Rehabilitation

I have previously written about sexual function and how it changes after prostate cancer surgery.

As men are being diagnosed with prostate cancer at a younger age and at an earlier stage, the preservation of erectile function and the ability to maintain satisfactory erections has become more important. My partners and I offer a variety of options to assist in the recovery of erections including having a vacuum device specialist come in to the office once a month, teaching patients how to give penile injections and intra-urethral suppositories, and prescribing viagra, levitra, and cialis on a maintenance, preventative basis.

One of the most frustrating things is insurance companies not paying for maintenance medicines even though most urologists feel these medicines help erections return sooner and possibly more fully. There was an excellent review of the literature by Dr. McCullough of NYU that I read this weekend. He is one of the world’s authorities on erectile dysfunction.

This is a great source of information for urologists who can receive 1.5 CME credits.
I will start giving this link out to patients with a letter to see if it helps get them at least partial payment from insurance companies.
I hope patients report any positive experiences with insurance companies paying for their PDE5 inhibitors after surgery.

I have been personally prescribing 1/2 of a pill of the maximum strength to be taken on Mon, Wed, and Friday evenings.

Robotic surgery summary- September 2007

In September I performed 19 operations including 13 dvPs.
One simple prostatectomy was combined with a left inguinal hernia repair. This was the first time I had performed this combination, although I have performed close to 50 hernia repairs at the time of dvP.
The new thing to report is an improvement in continence that I have seen after adding a few sets of sutures to re-construct the pelvic anatomy after removal of the prostate and before the connection is made. I had been doing part of this since I read a paper from Rocco describing his procedure of repairing anatomy behind the connection of the bladder to the urethra. This addition has helped more men achieve quicker urinary control in my experience.
Dr. Tewari has added an additional technique to reconnect the anatomy in front of the connection site.
I have added some of my own modification and have seen a nice short term improvement in urinary control. The best part is that the cancer control has not been compromised in these patients and my positive margin rate has declined.

3 experts discuss their experience with robotic surgery

Symposium: Robotic surgery in urology: Hype, hope, and reality – Modern Medicine

Community urologists who want to learn this must have an adequate volume of cases, at least 20 prostatectomies a year, and it probably will take 20 or 30 procedures before they are comfortable. For someone doing less than 20 cases a year, it doesn’t make much sense. You have to do this procedure with some regularity to keep up your skills.

Pruthi: I hesitate to suggest a number because of the different issues we have mentioned. In the Henry Ford experience, when they looked at complications, the learning curve was 200 cases.

2 At Vanderbilt, the surgeon-reported learning curve was 250 cases.

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Veil of Aphrodite at the time of robotic prostatectomy

UroToday – AUA 2007 ABST[550] Curtain Dissection of the Lateral Prostatic Fascia and Potency Following Laparoscopic Radical Prostatectomy – A Veil of Mystery

Conclusions: CD produced a significantly higher potency rate at 1 month following LRP but similar rates thereafter, which are in step with previously reported values (Rozet, 2004). Notably, CD failed to reproduce the results of Menon et al. despite the advantage of avoiding cautery at all stages during NVB preservation in our patients. We believe that the merit of this technique is in allowing a clearer appreciation of the contour of the prostate base at the commencement of antegrade NVB dissection, rather than preserving important nerve fibres. This may explain the lower basal positive margin rate in the CD group of 0% vs 5.8% in control cases (p=0.007).

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Surgical volume related to cancer cure rates after prostate cancer surgery

UroToday – AUA 2007 – The Effect of Surgical Volume on the Rate of Seconday Treatment After Radical Prostatectomy

They conclude that surgical volume is a determinant of treatment-failure when evidenced by the use of secondary therapies. Surgeons performing 24 RPs per year had the lowest rate of secondary treatment use.

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Rhode Island joins robotic community

Robotic surgery on prostate cancer arrives in R.I. | Rhode Island news | Rhode Island news | projo.com | The Providence Journal

This is robot-assisted surgery — and some say it’s the future of surgery. Miriam Hospital is the first hospital in the state to acquire the robot, called the da Vinci Surgical System, which makes it easier to operate in the tighter corners of the human body.

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