Robotic laparoscopic surgery: cost and training

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

[Sacral root neuromodulation. Experience in our site: 1998-2003, concerning 18 definite neuromodulation implants]

OBJECTIVE

Sacral root neuromodulation is an effective technique for the treatment of Chronic Micturition Dysfunction (CMD) refractory to conventional therapy. New indications such as chronic pelvic pain and interstitial cystitis are currently making their way within the urologic setting. Several groups of gastric surgeons are now choosing this technique for the management of rectal diseases (constipation, sphincter dysfunction). This paper contributes our experience in the treatment of patients with CMD and the comparative results at one year from implant in all patients.

MATERIAL AND METHODS

From December 1998 through July 2003, 18 neuromodulation definite implants were performed. The main indication was CMD in 62.5% patients. Follow up of patients was done at one month and three months, and every six months thereafter. Follow up is conducted through a micturition diary and QoL questionnaire. Electrode implant in the first 16 patients was achieved by open surgery. The next 2 patients had the electrode placed by a percutaneous technique using the "Tined Lead" kit.

RESULTS

Results at one year after implant were compared in all patients. The total number of neuromodulation implants placed was 18, 14 (77.7%) of which were women and 4 (22.3%) men. Mean age was 52.56 years. Implant indication was CMD in 72.2% patients, mixed incontinence (urinary and faecal) in 22.1%, and interstitial cystic disease in 5.5%. Symptoms improvement at one year from implant, as determined by a micturition diary and QoL questionnaire was 76.4%. Clinical improvement was greater in patients with urgency symptoms than in patients with predominance of voiding symptoms.

[Testicular torsion in the geriatric patient. Review of the literature apropos of a case]

Testicular torsion in adult, is an uncommonly etiology, but we should make differencial diagnosis in every person over thirty years old, with acute scrotum. The wrong diagnosis raises the incidence orchiectomy in adults for vascular etiology. We report a male of 74 years old with acute scrotum and review of the literature.

[Ureteral stenosis after kidney transplantation: treatment with a self-expanding metal prosthesis]

OBJECTIVE

To determinate the efficacy in the treatment of ureteral estenoses after renal transplantation with metallic self-expandable stent.

MATERIALS AND METHODS

From october of 1995 to april of 2002, 8 ureteral obstruction post renal transplantation have treated by means of implants of a metallic self-expandable stent (6 men and 2 women). The average time of pursuit was of 30 months (rank 2-53 months). In this work the severity and location of the estenosis are analysed, the method of implant of the stent, the permeability of the same one, the levels of creatinine pre and postimplant and the complications derived from the same one.

RESULTS

The treatment was effective in the 100% of the patients (8/8), with an average reduction of the creatinine of 36% (rank 13.6%-59.6%). The complications were minimum and the hospital stay was short.

CONCLUSIONS

In the patients with: chronic deterioration of the graft with short functional expectation, patient with high surgical risk and reestenosis after ureteral reimplantation by previous ureteral estenosis, the use of a metallic self-expandable stent, constitutes technique of election given its efficacy and low associate morbidity.

[Bladder malacoplakia with lymphatic involvement and an aggressive course]

Malacoplakia is an unusual chronical granulomatous disorder. In the urinary tract is more frequent in female, in 75 percent of cases involve the bladder. Pelvis extension of this disease is infrequent, and even less frequent is the involvement of pelvic and retroperitoneal lymph nodes. We present the second case in the literature of bladder malacoplakia with extravesical and pelvic node involvement.

[Metachronous solitary contralateral adrenal metastasis of primary renal carcinoma: report of a new case]

OBJECTIVE

To report a case of solitary metachronous contralateral metastasis of a renal carcinoma that had been previously resected.

METHODS

A 63-year-old male that had previously undergone a right radical nephrectomy due to renal carcinoma is presented. The patient's left breast was found to be slightly larger at the control evaluation 24-months postoperatively. Analytical and hormonal studies showed no significant findings except for a serum creatinine value of 1.75 mg/dl. However, a CT scan showed a left adrenal nodule of 3 cm. After 6 months of watchful waiting, the nodule had increased to 4.3 cm. A CT-guided fine needle punction aspiration biopsy demonstrated a malignant lesion and a left adrenalectomy was performed.

RESULTS

Histopathological analysis of the surgical specimen showed adrenal metastasis of clear cell renal carcinoma. At 21 months' follow-up after adrenalectomy, there is no evidence of recurrence of the metastasis.

CONCLUSIONS

This type of lesion is uncommon. We emphasize the importance of the analytical and hormonal studies, as well as CT and FNPA, in the diagnosis of this adrenal pathology. Like other authors, we advocate performing adrenalectomy in these cases.

[Replacement of prosthesis of the penis]

OBJECTIVE

To analyze the series of patients who underwent replacement of their penile prosthesis between years 1990 to 1999, due to any kind of complication.

MATERIAL AND METHODS

85 patients underwent implantation, 13 different prosthesis models being utilized. It was replaced (once or more) in 15 of these patients (17.64%). The mean age at the moment of the replacement was 51.5 years. The most frequent surgical approach was the infrapubic one.

RESULTS

A total of 32 prosthesis-replacement interventions were carried out. The main causes were: mechanical failure (13 cases, 40.62%); infection (10 cases, 31.25%); and corpus cavernosum perforation (five cases, 15.62%). Progressive increase of complications incidence with regard to the ordinal number of the implanted prosthesis was not observed. Best overall results: Mentor Mark II and AMS 700 Ultrex Plus. At present day, only eight (53.33%) out of 15 reimplanted patients use their prosthesis with normality.

CONCLUSIONS

Those patients who undergo replacement of their penile prosthesis are potential sources for later complications. Their knowledge and proper handling is important in order to a progressive improvement of the final results, (above all if--such as our case--these ones are not suitable for conformity).

[Lymphadenectomy in squamous carcinoma of the penis: review of our series]

OBJECTIVE

To analyze the series of patients who underwent inguinal lymphadenectomy in our Center due to squamous penile carcinoma, between years 1984 to 1999.

MATERIAL AND METHODS

Lymphadenectomy was carried out in 19 patients, with a mean age of 61 years. Bilateral ilioinguinal (42.1%) was the most frequent type of intervention. Only four patients underwent penectomy and lymphadenectomy simultaneously. We present the clinical and pathological results, according to the 1997 TNM classification.

RESULTS

Palpable inguinal nodes after antibiotherapy remained in seven out of 12 patients. The overall correlation between N and pN stages in our series was 68.42%. Pathological results according to pT and pN stages are also presented. Postoperative complications were present in 13 cases (68.42%), (lymphedema being the most frequent one). In those patients with two or less pN(+) nodes, an overall one-year and five-year survival of 90 and 80% were obtained; compared to 11.11 and 0% when there were more than two.

CONCLUSIONS

The importance about control of metastatic lymph nodes in squamous carcinoma of the penis, places inguinal lymphadenectomy as an essential tool, in those suitable cases. However, its incidence of complications makes a progressive agreement about its indications be necessary.