Prospective randomized study of radiofrequency versus ultrasound scalpels on functional outcomes of laparoscopic radical prostatectomy

An umbrella review of the surgical performance of Harmonic ultrasonic devices and impact on patient outcomes

BACKGROUND

For thirty years, the Harmonic scalpel has been used for precise dissection, sealing and transection. There are numerous meta-analyses on individual surgical procedures with Harmonic, but no overarching review covering all the areas. This umbrella review seeks to summarize the clinical results from the use of Harmonic across surgical fields and broadly quantify its effects on patient outcomes.

METHODS

MEDLINE, EMBASE, and Cochrane Databases were searched for meta-analyses (MAs) of randomized controlled trials (RCTs) comparing Harmonic devices to conventional techniques or advanced bipolar (ABP) devices. For each procedure type, the most comprehensive MAs were evaluated. RCTs not already analysed in a MA were also included. Operating time, length of stay, intraoperative blood loss, drainage volume, pain, and overall complications were evaluated, and the methodological quality and certainty of evidence were assessed.

RESULTS

Twenty-four systematic literature reviews were identified on colectomy, hemorrhoidectomy, gastrectomy, mastectomy, flap harvesting, cholecystectomy, thyroidectomy, tonsillectomy, and neck dissection. There were also 83 RCTs included. In every MA evaluated, Harmonic devices were associated with either statistically significant or numerical improvements in every outcome compared with conventional techniques; most MAs reported a reduction in operating time of ≥ 25 min. Harmonic versus ABP device MAs in colectomy and thyroidectomy showed no significant differences in outcomes.

CONCLUSION

Across surgical procedures, Harmonic devices demonstrated improved patient outcomes for operating time, length of stay, intraoperative bleeding, drainage volume, pain, and overall complications compared to conventional techniques. Additional studies are required to assess differences between Harmonic and ABP devices.

Tissue sealing versus suture ligation in open canine ovariectomy: Surgical times, intraoperative nociceptive response and frequency of complications

BACKGROUND

In this study, we compared two different techniques currently used for open canine ovariectomy: traditional method utilising absorbable suture and vessel sealing device (ENSEAL^® Ethicon Endo-Surgery, Cincinnati, OH).

OBJECTIVES

The aim of this study was to compare the surgical times, intraoperative nociceptive response and the frequency of intraoperative complications in the canine ovariectomy procedure using these two techniques.

METHODS

Forty bitches were randomly divided into two groups. The Control Group (C) will use a classic open surgery approach using ligatures with absorbable suture and ovarian resection with a scalpel blade. In the Group E, resection of ovarian structures was performed with ENSEAL^® tissue sealer device. For each dog the surgical times, the intraoperative nociceptive response (measuring heart rate, respiratory rate and non-invasive blood pressure) and the intraoperative complications were measured to compare the effectiveness of the two techniques.

RESULTS

The results of this study showed that the procedures performed using ENSEAL^® were faster than the traditional techniques using surgical suture. Instead, the results regarding the nociception and the safety of the two procedures are similar.

CONCLUSIONS

The present study shows that the use of ENSEAL^® significantly shortened the surgical time. Meanwhile, its use was found to be similarly safe and efficient in terms of intra-operative nociception, as the classical techniques with absorbable suture. Canine ovariectomy using ENSEAL^® device is more practical and faster than the traditional technique; the routine use of this device is considered a useful alternative for the canine neutering.

Different Nerve-Sparing Techniques during Radical Prostatectomy and Their Impact on Functional Outcomes

Simple Summary

Optimum preservation of potency and continence after radical prostatectomy (RP) are equally important surgical endpoints as cancer control itself. Nerve-sparing technique during RP has a major impact to both oncological and functional outcomes of the procedure and various different techniques have been developed aiming to optimize its outcomes. This literature review aims to summarize all different nerve-sparing techniques applied during RP from its first description from Patrick C. Walsh to its newer trends. The review underlines that optimum nerve-sparing expands far beyond recognising and preserving the anatomical integrity of the neurovascular bundles. It also emphasises that nerve-sparing is a field under constant development, with new technologies entering continuously the nerve-sparing field corresponding to the evolving open, laparoscopic and robotic-assisted RP approaches.

Abstract

The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords “nerve-sparing”, “techniques”, “prostatectomy” and “outcomes”. Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary.

[Update on laparoscopic electrosurgical devices and their use in complex urologic procedures]

INTRODUCTION

Laparoscopy is the standard of care for many urologic procedures and witnesses nowadays technological advancements. Hemostasis is highly important in laparoscopy since bleeding could rapidly alter the operative conditions. The objective of this review is to expose the different electrosurgical techniques, their history and their applications in urology.

MATERIAL AND METHODS

A literature review was overdone using the following terms "laparoscopic electrosurgery" and/or "nephrectomy" and/or "prostatectomy". Two hundred and forty articles were found through Pubmed. After reviewing the title and the content of these articles, 18 were eligible for the following review.

RESULTS

The different electrosurgical techniques and their technological evolution are exposed. Physical properties of each system are exposed as well. Advantages and limitations of each system are also reviewed and analyzed.

CONCLUSION

Bipolar electrosurgery with thermofusion and ultrasound technology can achieve good results in terms of nerve sparing for radical laparoscopic prostatectomies. They can both be used in partial nephrectomies. However, they can compromise the surgical resection margins. Hybrid systems seem to have an important role in urological laparoscopic procedures despite the scarce number of available studies.

LEVEL OF EVIDENCE

3.

A Surgical View of Photodynamic Therapy in Oncology: A Review

Clinical photodynamic therapy (PDT) has existed for over 30 years, and its scientific basis has been known and investigated for well over 100 years. The scientific foundation of PDT is solid and its application to cancer treatment for many common neoplastic lesions has been the subject of a huge number of clinical trials and observational studies. Yet its acceptance by many clinicians has suffered from its absence from the undergraduate and/or postgraduate education curricula of surgeons, physicians, and oncologists. Surgeons in a variety of specialties many with years of experience who are familiar with PDT bear witness in many thousands of publications to its safety and efficacy as well as to the unique role that it can play in the treatment of cancer with its targeting precision, its lack of collateral damage to healthy structures surrounding the treated lesions, and its usage within minimal access therapy. PDT is closely related to the fluorescence phenomenon used in photodiagnosis. This review aspires both to inform and to present the clinical aspect of PDT as seen by a surgeon.

Laparoscopic radical prostatectomy after previous transurethral resection of prostate using a catheter balloon inflated in prostatic urethra: Oncological and functional outcomes from a matched pair analysis

OBJECTIVES

To explore the surgical, oncological and functional outcomes of laparoscopic radical prostatectomy in patients who have undergone transurethral resection of the prostate, using a catheter balloon inflated in the prostatic urethra.

METHODS

A total of 25 patients were randomly assigned to the no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group (n = 12) and the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group (n = 13). Two matched pairs analyses were carried out to identify the 12 (control A) and 13 (control B) surgery-naïve patients. The outcomes were compared between the groups with previous transurethral resection of the prostate (no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy groups) and the controls. The rate of intra- and postoperative complications was assessed. The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Index of Erectile Function 5 were used for symptoms evaluation.

RESULTS

The mean blood loss was higher in patients submitted to transurethral resection of the prostate, with statistically insignificant reduced blood loss in the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group. The no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group had longer operative time compared with both the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and control A groups (P < 0.05). International Index of Erectile Function 5 showed a significant difference between no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and its control group; the International Consultation on Incontinence Questionnaire showed a statistically significant difference (P < 0.05) between the no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and control A groups.

CONCLUSION

The use of a catheter balloon inflated in the prostatic urethra seems to facilitate laparoscopic radical prostatectomy in patients with previous transurethral resection of the prostate, ultimately reducing the rate of perioperative complications. These findings warrant further investigation on a larger case series with a longer follow up.

Videourodynamic evaluation of intracorporeally reconstructed orthotopic U-shaped ileal neobladders

OBJECTIVE

To study the functional outcomes of 30 patients who had previously undergone laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder reconstruction using videourodynamic (VUDM) assessment 180 days postoperatively.

METHODS

Between November 2010 and December 2013, 30 male patients had undergone laparoscopic radical cystectomy with bilateral standard pelvic lymphadenectomy and pure laparoscopic orthotopic ileal U-shaped neobladder diversion. The demographic data were as follows: median age, 67 years (range, 62-79); body mass index, 22.3 kg/m(2) (range, 16-26.1 kg/m(2)); and mean American Society of Anesthesiologists score 2.2 (range, 1-3). Functional outcomes were assessed performing a standard VUDM study combined with perineal floor electromyography 180 days postoperatively.

RESULTS

VUDM evaluations showed good functional outcomes of the reservoirs. Mean maximal neobladder capacity was 287 mL (range, 210-335 mL). Residual peristaltic activity was observed in all the individuals evaluated; however, only 9 of 30 individuals (30%) displayed severe peristaltic activity. Six of these 9 individuals (66.6%) experienced urinary leakage during these contractions. Mean postvoid residual volume was 44 mL (range, 0-105 mL), and peak flow rate was 13.9 mL/s (range, 9.7-29.2 mL/s). The Valsalva maneuver was positive in 5 of 30 subjects (17%). Bladder morphology assessed during contrast cystography showed the desired U-shape in all cases. Ureteral reflux was observed in 7 of 30 individuals (23.3%).

CONCLUSION

Based on VUDM, our study shows that U-shaped ileal neobladders achieved by a totally laparoscopic approach obtained good functional outcomes. These findings support the evidence that a minimally invasive approach does not impose technical limitations that negatively impact the surgical results.

Pure intracorporeal laparoscopic radical cystectomy with orthotopic "U" shaped ileal neobladder

Background

Radical cystectomy with pelvic lymph node dissection represents the standard treatment for muscle-invasive, and high-risk non-muscle-invasive bladder cancers. Aim of this study was to report our case series of 30 patients undergoing totally laparoscopic radical cystectomy (LRC) with reconstruction of an intracorporeal orthotopic ileal neobladder. Intra- and perioperative results and the functional and oncological outcomes 9 months after operation are reported.

Methods

Between October 2010 and December 2012, 30 male patients underwent LRC with a pure laparoscopic orthotopic ileal “U”- shaped neobladder diversion. The men had a median age of 67 years, a median body mass index of 22.3, and a mean ASA score of 2.2; they represented various clinical stages of disease.

Results

None of the patients required conversion to open surgery, and no perioperative mortalities were reported. The median operating time was 365 min, and the median blood loss was 290 mL, with a transfusion rate of 26.6%. All surgical margins were negative; 8 patients with non–organ-confined disease or positive lymph nodes received adjuvant chemotherapy. Early complications (within 30 days) occurred in 7 patients, and late complications occurred in 6 patients. The mean hospital stay was 9 days. At 9 months after surgery, the daytime continence rate was 83.3% and the nighttime continence rate was 73.3%.

Conclusions

Pure LRC with intracorporeal orthotopic ileal neobladder reconstruction may represent a viable alternative to open radical cystectomy, with a significant reduction in patient morbidity. Future, large, randomized controlled trials with extensive follow-up are needed to confirm our encouraging results.

[Suture materials in urology]

Since ancient times, sutures have been a fundamental part of the surgeon's practice. Beside the vegetable and animal origin materials, in the last decades different refined synthetic materials have been introduced in the clinical practice. More recently, different devices, such as staplers and tissue sealers have been developed. Thus, more than ever, urologists are faced with a multitude of suture materials, and research of safe, effective materials and devices seems to be continuously growing. The introduction and widespread diffusion of laparoscopic and robotic surgery has further boosted this research. Given there is no single material that is ideal for all situations, the surgeon must choose the best material for each particular case.
The aim of this non-systematic review is to summarize the more innovative suture materials and devices and to describe the different surgical methods to utilize them both in general and in urologic surgery.