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PUA 63rd Annual Convention Plenary Session One

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The first series of lectures of the 63rd Philippine Urological Association, Inc. Annual Convention 2020 featured esteemed colleauges from the EAU section of Uro technology (ESUT) who are in the forefront in their own respective fields with focus on Uro-technology. The speakers who shared their valuable knowledge presented the latest developments and updates in their said fields and gave concise discussions which were highly educational.

Plenary session 1 was divided into 2 categories. The following were the lectures included in the session:

Prone Endoscopic Combined Intrarenal Surgery (ECIRS) by Dr Otas Durutovic, Associate Professor of Urology from the Clinic of Urology, University of Belgrade, Serbia

Dr Durutovic discussed the essentials in the performance of ECIRS with the concept of the “Perfect Puncture”; he also discussed the evolution of the positioning of patients in percutaneous nephrolithotomy (PNL) and its pros and cons. He also described the ECIRS; the difference between a prone and a supine ECIRs and both its advantages and disadvantages. Dr Durutovic briefy discussed the value of surgeon ergonomics in the surgical procedure and its short and long term effects. In conclusion, prone ECIRS is a relatively new concept in stone surgery with scarce data, it is a feasible option in the management of renal stones however it has the disadvantage of the need for two experienced urologists, additional OR setting necessary

REZUM for Prostate Treatment by Evangelista Martinelli, MD; Urology Consultant, European Association of Urology – Italy

Dr Martinelli discussed in brief the use of the Rezum system water vapor treatment for lower urinary tract symptoms/ Benign Prostatic Hyperplasia and he briefly presents the effect of this procedure on treated patients in a 3 month period of time. He then proceeds to discuss the procedure as to the proper placement of the needle and the correct manner of vapor delivery. Dr Martinelli then presents a semi-live surgery showing the actual procedure whereby essential steps have been given emphasis and critical steps were discussed. Pearls and comon pitfalls were discussed and more importantly what necessary measures are to be instituted in order to avoid them. Dr Martinelli discussed on the common complications after the procedure and the clinical course of the patient with the subsequent follow-up check up.

In conclusion, convective radiofrequency thermal therapy with the Rezum system warrants consideration as a first line treatment for LUTS/ BPH as an alternative to the use of pharmaceutical agents; it may also warrant a position as a procedure for LUTS relief both as an initial therapy versus pharmacotherapy and as an alternative to transurethral surgery for selected patients. An added advantage of the Rezum Systme is the provision of effective and durable symptom relief, without any significant side effect and the preservation of antegrade ejaculation in more than 90% of patients

Holmium Prostate Enucleation by Lufti Tunc, MD; Urology Consultant, Gazi University, School of Medicine, European Association of Urology – Turkey

Dr Tunc presented with the idea that Holmium Laser Enucleation (HoLEP) as the gold standard for the surgical management of BPH in the 21st century, he then showed the comparison between the Thulium Laser enucleation (ThuLEP) in terms of the publications; Dr Tunc highlighted that with regards to the use of this surgical modality, the hesitancy may arise from dilemmas and misunderstandings with regards to the procedure; he further higlights on the difference on the stance of the American Urological Association (AUA) and the EAU guidlines with the use of laser enucleation in patients with benign prostate enlargement; further he discusses on the different terminologies used by different authors on the matter and higlights the confusion and lack of concensus.

Dr Tunc then discusses the techniques in the performance of HoLEP and that the main goal of the procedure is the protection of the external urethral sphincter to preserve continence; he then discusses the practical anatomy of the external sphincter and correlates such in the performance of HoLEP. He then discusses the omega signe technique which adapts the 3-lobed techniques with modification of protecting the sphincter at the 12 o clock position at the prostatic apex by leaving sufficient mucosal layer in the external sphincter to prevent incontinence.

En Bloc Resection of Bladder Tumor by Salvatorre Micalli, MD; Full Professor of Urology, Director if Urology Residency Training Program at the University of Modena & Reggio Emilia; European Association of Urology – Italy

Dr Micalli presents the importance of a complete resection of a bladder mass with emphasis on the en-bloc resection of the bladder mass; he presents the scenarios where an en-bloc resection can be performed. He begins the discussion by presenting the global statistics on bladder cancer. Dr Micalli then discusses briefly on non muscle invading bladder cancer (NMIBC) and emphasizes that surgery in the form of trans urethral resection of bladder tumor (TURBT) followed by pathologic examination as the first therapy.

Dr Micalli then proceeds to discuss the differences between classic TURBT from and en-bloc TURBT with its advantage and disadvantage; he then shows how hsitopathological assessment between the two types of TURBT differ with emphasis on the improvement in quality of histopathological specimens in en-bloc TURBT with correct orientation, correct identification of cancer growth front and the horizontal and vertical extent of specimens as opposed to the piecemeal fractions of classic TURBT. In addtion, en-bloc TURBT for NMIBC allows for easier identification of chorion invasion.

In conclusion, En Bloc resection of Bladder Tumors (ERBT) is a promising alternative to conventional TURBT; it offers the advantage of having a high rate of detrusor muscle inclusion (>95%) and specimens of high qulaity for pathological evaluation. With regards to the complications, limited data shows that there are no significant differences between perioperative morbidity and recurrence rates. Evidence also shows that EBRT has comparable safety and oncologic equivalence with the standard TURBT. Lastly, it was noted that lateral mucosal margin is detectable only in EBRT specimens.

Retroperitoneal Robot- Assisted Radical Prostatectomy by Jans Rassweiler, MD; Professor of Urology, SLK Klinikien Heilbronn, University of Heidelberg; EAU Section Head, President, Endourological Society – Germany

The active pursuit of both knowledge and technique are the core values of a surgeon and in the past years the advancement of surgery has been on a steady rise.

Dr Micalli discusses such advances with the presentation of the Robot Assisted Extraperitoneal Laparoscopic Radical prostatectomy : the Heilbronn-Technique. He begins the discussion with the presentation of the indications of extraperitoneal laparoscopic surgery in urology and indications of laparoscopic radical prostatectomy.

Dr Micalli emphasizes on the basic neurophysiology of continence and the importance of the careful handling of pelvic floor innervation in the maintenance of post operative continence. He then discusses the preservation of the levator fascia in the Heilbronn technique and entry into the endopelvic fascia as its alternative.

Dr Micalli discusses the procedure with the accompaniment of a semi live surgery video, with emphasis on techniques in order to imporve early continence as the preservation of the puboprostatic collar and the preservation of the levator fascia.

In summary, robot assisted laparoscopic radical prostatectomy has an acceptable learning curve of a stadardized technique; it provides excellent functional outcomes and excellent oncologic outcomes.

Laparoscopic Partial Nephrectomy (with Selective Clamping) by Allen Sim, MRCS (Edin), FAMS (Singapore), FRCS (Glasg); Consultant Urologist, Gleneagles Medini Hospital, Malaysia

Singapore General Hospital

Dr Sim presents the techniques are performed in the performance of partial nephrectomy with the goal of nephron sparing. He highlights that the goal is the minimization of warm ischemia time and volume preservation by precise excision. Further, Dr Sim briefly presents the different scoring systems which are applied when considering the surgical planning for renal tumors.

He presents the concept of the intraparenchymal tumor volume (IPV) in assessment of patients undergoing partial nephrectomy with the conclusion that the IPV is an objective, readily measureable CT based radiologic score that combines 2 aspects of tumor complexity being size and percentage endophytic component.

He concludes that IPV is a novel parameter which correlates with perioperative renal outcomes, in particular the high IPV category (>27.26 cm3) however IPV has yet to reach the significance with other surgical outcomes. As a single parameter, IPV has shown good correlation with existing multiparemater RENAL nephrometry scores.

To minimize neprhon loss, mimimization of warm ischemia time and precise excision is performed.

Options for the minimization of warm ischemia time were discussed with emphasis on the difference in advantage and disadvantages; superselective clamping, early unclamping and completely off-clamp (zero ischemia) were concisely discussed.

Further, Dr Sim discussed the utlity of Indocyanine green (ICG) in renal surgeries with emphasis on its role in identification of specific vasular territories to facilitate super selective clamping in partial nephrectomy; he discusses on the advantage in performing ICG injjection as well as the pitfalls of the procedure.

In conclusion, Dr Sim discussed on the importance of preservation of renal function in partial nephrectomy; he highlighted the use of IPV in the manangement of partial nephrectomy. He also highlights the feasibility of super selective clamping with the aid of ICG. With regards to the future, tumor enucleation might be the way forward with regards to anatomical considerations, less parenchymal loss and less bleeding.

Smart Operating Rooms with New Technologies by Jans Rassweiler, MD; Professor of Urology, SLK Klinikien Heilbronn, University of Heidelberg; EAU Section Head, President, Endourological Society – Germany

Dr Rassweiler begins his discussion on the history of surgery until the present time; he emphasizes in the technological advances which has developed through the years of research and development.

He briefly discusses on the concept of surgery 4.0 which cyber physical systems and an internet of machines are available.

He discusses that sugrery 1.0 is open surgery, surgery 2.0 is laparoscopic surgery, surgery 3.0 is robotic surgery which is a bridge between the laparoscopic and digital surgery, and surgery 4.0 is digital surgery. Further discussion on surgery 4.0 showed that basic components for its fucntionality include an artifical intelligence, a capable robot/ MIS, an iltelligent operating room and on-line communication. When all these components are combined and act in concert, inevatible better outcomes are to be expected.

Drf Rassweiler reported that as of the present, we are in an era of surgery 3.0 where the DaVinci XI system is the gold standard; there are recent technologies where intra operative planning cen be done in a 3D/3D Fusion DaVinci which can show 3D screens at the console shown in quasi real time.

However it has been noted that the artifical intelligence necessary for an automated surgery 4.0 is not yet available.

For the time being, the surgeon is still at the core of medical-surgical pateint care and in keeping with the tradition, will always be.

NEW ROBOTIC PLATFORMS in the MARKET by ALI SERDAR GOZEN, MD

Chariman of the ESUT Training Group – Germany

Dr Gozen has presented to the convention the availability of surgical robots in the current market; he starts the discussion in giving the status of operations as th open surgery, traditional minimally invasive  surgrery (MIS) and robotic -assisted surgery. He highlights the wonder of the technology by presenting the trans atlantic laparoscopic cholecsytectomy performed on September 7 2001 where the surgeon and patient distance was New York City, USA and Strasbourg in the eastern border of France with Germany.

Dr Gozen then proceeds to present the different surgical robots which are available and will be available in the market within the immediate future. He further discusses in the advantages and disadvantages of each system as well as on the relative cost of each machine.

In conclusion, the demand for robotic surgery continues to grow exponentially with new systems being developed; in the advent of new modifications, each machine has their specific advantage and disadvantage. These new surgical robots will lead to competition and definitively reduce the cost of robotic surgery in the near future. All these factors will lead to an increase of the use of robotic-assisted surgery in urology.

The plenary session was then concluded with the closing remarks by dr Samuel Vincent G. Yrastorza, President of the EAU – Philippine Chapter.

As the PUA launches the 63rd Annual Convention and the first done on an online platform, this has been an undeniable success. The PUA has not only adapted to the times but it has risen above the challenge given by these unusual circumstances. This pandemic may have closed our physical borders however by sheer will and initiative of the PUA, the PUA has opened the global avenues for learning and camaraderie.

Mabuhay ang PUA!

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Ray Raphael Tan de Guzman, MD.

Ray Raphael Tan de Guzman, MD.

Urology, First Year Resident, VIcente Sotto Memorial Medical Center, Cebu City, Philippines

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