Abstract
One dilemma facing urologists is the increased use of chronic oral antiplatelet therapy (OAT) for patients with a history of coronary stents or cerebral stroke. The safety of OAT during RARP has yet to be delineated. Mortezavi et al. 1 compared 38 RARPs performed on patients while taking chronic OAT with 76 control RARPs performed on patients not on OAT; there was no statistical difference between the groups with regard to postoperative hemoglobin change, complications, or urinary catheter time. However, the only 2 patients who required blood transfusions in the series were in the OAT group. The authors themselves note that no source of bleeding could be found in these 2 patients, signifying diffuse pelvic oozing in my mind. Although OAT appears to be safe during RARP, the risk of diffuse pelvic bleeding exists, and further study needs to be done in this arena. The authors also do not note the effect that OAT may have on long-term functional outcomes following RARP (erections, continence).
Renal hilum clamping used during partial nephrectomy leads to WIT that will injure renal parenchyma if prolonged. Jeon et al. 3 note that the use of unidirectional barbed suture for renorrhaphy during laparoscopic partial nephrectomy performed by a single experienced surgeon decreased mean WIT from 31.9 minutes to 24.5 minutes compared with the use of standard suture. The authors note that the elimination of suture backsliding offered by the unidirectional “V-lock” suture allows for continual hemostatic tension during the most complex portion of the procedure (renorrhaphy), thereby lowering WIT. The suture does offer an additional expense to the procedure but may be worth the cost to preserve nephrons during this complex, minimally invasive procedure.
En bloc stapling of the renal hilum during laparoscopic nephrectomy has been shown to be easier and faster than ligation of the renal artery and vein separately. However, the theoretical risk of arteriovenous fistula (AVF) and the difficult management of AVF make many urologists cautious of en bloc stapling of the renal hilum. Chung et al. 4 report data from the first randomized, controlled trial of en bloc stapling (35 patients) versus individual artery/vein ligation (35 patients) during laparoscopic nephrectomy. This trial was well designed, with both groups being similar with regard to renal mass size, and the trial offers excellent 1-year radiographic follow-up as well as physical exams (to evaluate for hypertension, etc.). En bloc stapling offered faster operative time with less risk of vascular injury (one renal vein injury in the separate ligation group) and no reported AVF over the follow-up period. This article provides more evidence to support a practice that many experienced laparoscopic urologists routinely perform. The authors' discussion section offers a nice hypothesis as to the mechanism of AVF formation and for the high risk of AVF noted in early series of en bloc renal hilum sacrifice.
Finally, our article 2 from the Mayo Clinic Florida outlines a mentorship training program for residents-in-training trying to learn RARP and provides benchmark data with regard to perioperative safety for residents performing RARP directly out of training. Most benchmark data in the literature with regard to RARP are from surgeons with thousands of cases or those who are fellowship-trained in RARP. This article notes that surgeons entering into practice directly from residency training can perform RARP safely with perioperative outcomes similar to those in the literature of experienced surgeons. This topic will carry more importance as the use of robotic surgery in urology for prostate cancer continues at its high levels and the training background of surgeons using the technology becomes more varied.
We hope you enjoy this edition of the Journal as it addresses some of the most common issues in the field of urologic surgery today. As usual, we hope that the techniques presented in this journal continue to improve your busy surgical practices in a safe, commonsense manner.