Assisted Laparoscopic Radical Prostatectomy Specimen Removal

Assisted Laparoscopic Radical Prostatectomy Specimen Removal Removing the specimen with traction during robotic radical prostatectomy Serkan Altinova, Abidin Egemen Isgoren, Ziya Akbulut, Muhammed Fuat Ozcan, Abdullah Erdem Canda, Ali Fuat Atmaca, Mevalana Derya Balbay Key words: Prostate cancer, radical prostatectomy, specimen, traction Abstract Purpose: Our aim was to show if removing the specimen with traction during robot assisted laparoscopic radical prostatectomy cause positive surgical margin or not. Materials and Methods: 169 patients with localized prostate cancer who were performed robot assisted laparoscopic radical prostatectomy were included in the study between 2009-2011. Patients were divided into 2 groups. Patients’ characteristics, preop and postop evaluation were recorded. Results: There were 111 and 58 patints in group 1 (with traction) and group 2 (without traction), respectively. Patients’ ages, follow up time, body mass indexes (BMI), prostate spesific antigen (PSA) values, preop and postop Gleason score values, pathological stage, positive surgical margin rates and biochemical PSA reccurrence rates were evaluated. There was no statistically significant difference between groups for age, preop PSA values, BMI, preop and postop Gleason scores, positive surgical margin rates and biochemical reccurrence rates. There was significant difference between prostate weight, tumor volume and clinical stage between groups. ( Conclusions: Removing the specimen with traction during robot assisted laparoscopic radical prostatectomy does not cause positive surgical margin. The incision can be as small as possible for cosmetic sight. Introduction Robot-assisted laparoscopic radical prostatectomy (RALP) has become the most preferred surgical technique for localized prostate cancer. One of the most important factor pointing out the oncologic success is the surgical margin status.(1) Positive surgical margin (PSM) status may be related both with the surgeon, surgical technique and disease burden. (1,2 ) Our aim was to evaluate the effect of traction, probably the cause of PSM, during the specimen removal. Ther are many studies comparing the PSM acording to techniques, pathologic findings and clinical stage but we found none acording the technique of specimen removal. (3) Materials and Methods 169 patients who were performed RALP for localized prostate cancer between 2009 and 2011 were included in this study. All the patients were evaluated and Ethic Committee permission were given for each. The reason why we planned this study was the patients with postoperative PSM (positive surgical margin) but no PSA (prostate spesific antigen) reccurrence. Patients were randomized as two groups, A and B, acording to their status of traction was done or not while removing the specmen. Traction can be defined as removing the specimen from a small incision that may let the specimen removed by traction. No traction can be defined as removing the traction from an incision larger than prostate that make easy removing the specimen without any difficulty. Student-t test was used for follow-up, age, BMI (body mass index), PSA, prostate weight and tumor volume. Chi-square test was used for Gleason grade, stage, SMI (surgical margin invasion) and BCR (biochemical reccurrence rates). All the values were calculated as mean and SD. SPSS 16 was used. Results Group A (traction group) had 111 patients while group B (no-traction group) had 58. There was statistically significant difference between groups for prostate weight, tumor volume and clinical stage. Age, BMI, preoperative PSA levels, biopsy Gleason score, prostatectomy Gleason score, pathological stage, SMI status and BCR were similar for both groups. Patients’ preoperative and postoperative characteristics are summerized in table 1 and 2. Although there are pT0 patients in both groups we have to say that we have given no additional therapy like androgen deprivation therapy preoperatively. Discussion Nowadays robot-assisted laparoscopic radical prostatectomy is the main surgical technique for localized prostate cancer. In the United States 85% of radical prostatectomies are performed robotically. (4) Generally PSM rates after different techniques for radical prostatectomy seems to be equal but sometimes surgical technique may effect the rates.(5,6) Oncologic outcomes of robotic surgery are generally similar with laparoscopic and open surgery (7-10) although there are some other results suggesting that the rates are different for the techniques. (11-13) The well known object is that the PSM may be related with disease burden, surgeon and also the technique. Robotic surgery has some differences from laparoscopic surgery. The adventages of robotic surgery are related both with the patient and the surgeon. This provides a comfortable operation for the surgeon. In order to find out if traction may cause a PSM, we randomised the patients into two groups as traction or non-traction. We believe that traction may cause a damage on the prostate capsula and show a pseudopositive surgical margin. In our study PSM rates are similar in both groups. Higher tumor volume and stage can effect PSM rates. (2) Although traction group has higher tumor volume rates and lower clinical stage PSM rates are similar. Also prostatectomy Gleason scores are similar for both groups. All the operations were performed by the same person as PSM rates can differ among surgeons performance. Some outhors have described â€Å" Capsular Incision Index† to show the damages on the capsula that may cause pseudopositive surgical margin.(2). We beleive, because of the traction made by the fourth arm of the robot may cause pseudopositive surgical margin, pahologist must reveal that if there is a positive margin coloured with the ink they use, they must also see the capsula of the prostate. If no, this may not be really a positive margin. This is very important as sometimes may affect the extra t herapy options. In order not to give any unneccesssary treatment both the surgeon and the pathologist must be very careful as this may not only increase the morbidity but also the cost. Conclusion Surgical margin status after radical prostatectomy is an important topic. Surgical technique is important in order not to cause a positive surgical margin but pathlogical findings are maybe more important for the possible additional treatment. Removing the specimen with traction during robot assisted laparoscopic radical prostatectomy does not cause positive surgical margin. The incision can be as small as possible for cosmetic sight. References Wiezer AZ, Strope S, Wood DP. Margin control in robotic and laparoscopic prostatectomy: What are the REAL oucomes. Urol Oncol. 2010; 28:210-14. Hong H, Mel L, Taylor J, Wu Q, Reeves H. Effects of robotic-assisted laparoscopic prostatectomy on surgical pathology specimens. Diagn Pathol. 2012; 7:24-30. Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: A systematic review and meta-analysis comparing retropubic, laparoscopic and robotic prostatectomy. Eur Urol. 2012; 62:1-15. Lowrance WT, Parekh DJ. The rapid uptake of robotic prostatectomy and its collateral effects. Cancer. 2012; 118:4–7. Philippou P, Waine E, Rowe E. Robot-assisted laparoscopic prostatectomy versus open: comparison of the learning curve of a single surgeon. J Endourol. 2012; 26:1002-08. Coelho RF, Rocco B, Patel MB, et al. Retropubic, laparoscopic and robot-assisted radical prostatectomy: a criticai review of outcomes reported by high volume centers. J Endourol. 2010; 24:2003-15. Parsons JK, Bennett JL. Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy. Urology. 2008; 72:412–16. Ficarra V, Novara G, Fracalanza S, et al. A prospective, non-randomized trial comparing robot-assisted laparoscopic and retropubic radical prostatectomy in one European institution. BJU Int. 2009; 104:534–39. Schroeck FR, Sun L, Freedland SJ, et al. Comparison of prostate-specific antigen recurrence-free survival in a contemporary cohort of patients undergoing either radical retropubic or robot-assisted laparoscopic radical prostatectomy. BJU Int. 2008; 102:28–32. Laurila TA, Huang W, Jarrard DF. Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients. Urol Oncol. 2009; 27:529–33. Williams SB, Chen MH, DAmico AV, et al. Radical retropubic prostatectomy and robotic-assisted laparoscopic prostatectomy: likelihood of positive surgical margin(s) Urology. 2010; 76:1097–1101. Cathcart P, Murphy DG, Moon D, Costello AJ, Frydenberg M. Perioperative, functional and oncological outcomes after open and minimally invasive prostate cancer surgery: experience from Australasia. BJU Int. 2011; 107(Suppl 3):11–19. Magheli A, Gonzalgo ML, Su LM, et al . Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. BJU Int. 2011; 107:1956–62. Table 1. Preoperative characteristics of patients Table 2. Patients’ postoperative findings 1

Discuss the following Essay

A staff meeting has been called for all members of the administrative department at the hospital where you work. Due to a change in patients’ needs, the hours of operation need to be modified.   Several scheduling options are presented and a decision has to be made. Should this decision be made by a majority vote, or a consensus? Support your choice with   reasoning from the decision making section on page 98 of your GMC. I think that due to the time and hours of operation that it should be a majority vote for the reason or reasons outlined below: 1.Since there is only the matter of counting votes, decisions can be reached much more quickly with majority rule. Majority rule does not require the same level of interpersonal communication. It is a democratic process which ultimately comes down to simple mathematics. This method of decision-making, outside of registration, is often anonymous. The nature of the process, in many cases, allows individuals to maintain their privacy, as others cannot know with certainty, for whom or what a person has voted. A disadvantage of majority rule is the majority’s ability to vote against the interests and preferences of those in the minority without those groups or individuals being heard or involved in the discussion. Those in the minority may be disenfranchised and remove themselves from the decision-making process because they are aware they do not have the numbers to win or significantly impact the vote.

Tale of Two Cites: Drowning Motif

English 12u Essay Rough Draft Justina Van Maren Splashing, gasping for breath. Sinking, darkness, and then; death. Death by drowning is, in the beginning, a conscious, agonizing end. The realization of an imminent death is the first step that strikes fear into the heart of the victim. Shore is too far away, the person is too tired, and if rescue is not near, death is inescapable. Contrary to popular understanding, a drowning person is not easy to spot. People picture a drowning victim screaming or calling for help, but in actuality all his/her efforts are used to breathe, making calls for help impossible.Drowning is not the death most people envision it. It is a silent killer. Creeping up slowly, it takes its victims by surprise, and often before five minutes have passed, death has them in its cold, cruel clutches. This silent action is paralleled in Charles Dickens novel, A Tale of Two Cities. Dickens speaks of a woodman, personified as fate, and a farmer, who is used to picture dea th, working silently but purposefully towards the French Revolution, getting ready wood for scaffolds, guillotines and tumbrels. As well as portraying the silent nature of drowning, Dickens also uses this motif to bring out another aspect of the revolution.In A Tale of Two Cities, Dickens uses the motif of drowning to portray the stages of the revolutionaries’ attitudes towards their condition. â€Å"The first step towards getting helped is realizing that you have a problem. † (Anonymous) This well known quote clearly illustrates the first step of drowning. A man cannot save himself if he does not realize that he is in danger. When drowning becomes reality to its victims, their whole vision changes, and panic sets in. In A Tale of Two Cities, the peasant’s vision changed as they realized that if they did not act right away, they would die as victims of a tyrannical system.If this fact in itself did not move the peasants into action, it was the fact that not only them, but their children and their children’s children would perish, smothered under the iron fist of the aristocracy. Their vision became visions of desperate people, as drowning people. This outlook was in many ways created and helped along by Monsieur and Madame Defarge. They showed the shrunken, wasted Doctor Manette to the Jacques, in order to change the way they looked at things and strike fear of their condition into their hearts. Dickens also uses the motif of drowning very strongly in the personal lives of his characters.A quote found on page 255 reads, â€Å"All this was seen in a moment, as the vision of a drowning man. † This quote refers us back to the Manette’s, where Jarvis Lorry reveals the terrible grindstone scene to the horrified Doctor. Doctor Manette’s vision changed at that moment as well, realising that death, though not for himself, was sure for Lucie’s husband if immediate action was not taken. When a drowning person obtai ns the vision that he or she is dying, panic takes control over both mind and body. From panic stems desperation and a desperate man is someone who will do anything to change his situation.A drowning man no longer thinks about right and wrong, about what morals he practices, or what values he ought to follow. One thought consumes his mind, and that is to save himself. The means used to achieve deliverance does not matter, nor does the suffering person stop to consider if he is harming another in saving himself. In the novel, this is illustrated by the conflict between Miss Pross and Madame Defarge; â€Å". . . Miss Pross . . . held her round the waist, and clung to her with more than the hold of a drowning woman,† (Dickens 357).This situation clearly reminds the reader of the desperate circumstances in which the peasants found themselves. Just as Miss Pross’ hold on Madame Defarge was a matter of life or death, so the actions of revolutionaries were determining their e nd; a better future for all peasants, or a continuation of oppression from the ancien regime. In the above quote Dickens also speaks about the hold of a drowning person. A rescuer must always be careful when swimming up to such a person, because in panic, the victim may grab hold of him/her so tightly that both perish.In the same way, the revolutionaries harmed others while trying to save themselves. In the senseless slaughter of those guilty and innocent alike, the revolutionaries drowned themselves along with their victims in a pool of immorality and revenge. For, even though they bettered their physical condition and brightened the future for their children, their conscience was passed over and ignored. Like a drowning man who before the actual act of death becomes unconscious, so the consciences of the revolutionaries were pushed away until they were silenced, no longer able to warn against the upcoming spiritual death. Death is the final outcome.If a person has drowned, death h as come to claim this person and there is no longer any chance of being rescued. In A Tale of Two Cities, Dickens speaks of the gaoler of Charles Darnay, his description being, â€Å". . . this gaoler was so unwholesomely bloated, both in face and person, as to look like a man who had been drowned and filled with water,† (Dickens 249). This man seems to point to all the revolutionaries, not in the physical description, but in a spiritual sense. The consciences of the revolutionaries have been drowned, silenced forever, and the people themselves have been filled with thoughts only of bloodthirsty revenge.The picture of a drowned man is not a pleasant one. The death is most often an agonizingly conscious one, causing the expression to be one twisted in agony, the horrified expression of one without hope of survival. The lack of oxygen causes the skin to turn a sickly blue, and the water soaks into the pores and causes the persons face to be swollen and bloated. Ultimately, the person’s appearance is so altered that it is usually difficult, if not impossible to identify the person from the way they looked before.Similarly, the revolutionaries were not a pretty picture in the way that they cared nothing for their fellow man and executed any who seemed to oppose them callously, without proof or proper trial. Proof of this callousness can be found in the example of the little seamstress towards the end of the novel, a representation of thousands of innocent victims sent to the guillotine. We read of how the women knitting below the scaffold counted the severed heads calmly, not in the least disturbed at the horrific amount of bloodshed occurring right before their eyes.The wood-sawyer is another prime example of the uncaring attitude of the peasants when he talks flippantly to Lucie of the guillotine; â€Å". . . Loo, loo, loo! And off her head comes! Now a child. Tickle, tickle; Pickle, pickle! And off its head comes. All the family! † (Dickens , 341). We are horrified as we read of the Jacques gleefully talking about the way they enjoy seeing a woman with blonde hair and blue eyes being guillotined, and we are even more appalled when they speak with eager anticipation at the thought of seeing Lucie’s pretty child put to death.Throughout all these examples we can see that Dickens has brought the motif of drowning to a close and the final outcome, death of the revolutionary’s morality, has been achieved. At the end of the novel, A Tale of Two Cites, the motif of drowning has come full circle. We read of how the peasant’s desperate situation causes their vision to be that of drowning people as they realize that death is imminent. Dickens moves on to portray the panic that causes morality to be ignored in the frantic attempt to preserve one’s own life.Dickens shows that drowning people will do anything to save themselves, even drown their rescuer if they feel it will improve their own condition. In the same way the revolutionaries brutally disposed of any that seemingly hindered their desperate attempt to break their chains of oppression. The plot lines of the characters also vividly portray the way in which the consciences of certain characters are silenced, and the way in which no other thought than revenge is allowed into the minds of the revolutionaries. And then finally, death, the end of all morality.The guiding principles of mankind were destroyed as the revolutionaries thirst for bloodshed did not abate, but instead grew more intense, as each day they longed for more heads to be added to the ever growing number. The motif of drowning is used very powerfully by Charles Dickens, and is employed in a way that effectively portrays the desperate position of the revolutionaries. The way in which Dickens uses this motif clearly parallels the changing attitudes of the revolutionaries, giving us a better understanding of them.

Beowulf And The Epic Hero - 1407 Words

In the epic hero poem, Beowulf, the main character Beowulf, is a prideful, boastful and extremely strong individual. He is faced with a few tasks during the course of the poem; the first of which is fighting and killing an evil, dangerous and disgusting creature, named Grendel, which terrorized the town of Herot. Soon after that, Grendel’s devious mother â€Å"the she-wolf,† attacks Beowulf and the town forcing Beowulf to fight her off as well. After the mother-son duo, Beowulf is then faced with the biggest task of his existence, both literally and figuratively. During each of these battles Beowulf fights and kills these creatures in different ways with different weapons and different tactics. He also changes during each fight, and at the end of the poem is quit a different man. How does he manage to fight each creature off and what kind of tactics did he use? Well that’s a great question, let me elaborate. First and foremost, Beowulf is a very strong warrior; he hails from the land of the Geats and is their best soldier. He is what many would call a thrill seeker and is drawn to danger, adventure but most of glory. Beowulf sets off in search of such glory and lets the seas take him where it may; this leads him to the town of Herot. Once there he is given a great opportunity by the great King Hrothgar, to prove his strength and obtain much glory. The task is to kill the terrible creature that haunts the town night after night, a creature named Grendel. Beowulf finds out moreShow MoreRelatedThe Epic Of Beowulf As An Epic Hero1519 Words   |  7 Pagesaway following a journey, you have most likely read an epic. An epic by definition is â€Å"a long poem, typically one derived from ancient oral tradition, narrating the deeds and adventures of heroic or legendary figures or the history of a nation†. 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Beowulf is described as an epic hero becauseRead MoreThe Epic Hero Of Beowulf866 Words   |  4 PagesAn epic hero is someone who is of great importance, they have supernatural abilities, have some form of connection with the Gods, and accomplish great deeds. In Beowulf, translated by Seamus Heaney, Beowulf is the epic hero in his tale and he is considered great by those who know of his life. There are two versions of his story which portrays him in a certain way. The video version does not do its best to portray him as an epic hero but instead show that he is a liar, a womanizer, and a coward. TheRead MoreBeowulf : An Epic Hero894 Words   |  4 Pages The character of Beowulf demonstrates several characteristics that make a great epic hero. Throughout his lifetime he displayed several characteristics such as honor, bravery, physical superiority, leadership, and glory. These characteristics all formed how the Anglo-Saxons believed one should live their life. Along with the valorous deeds that Beowulf accomplished he is considered to be a prime example of an epic hero. Beowulf would have even been considered a model human to the Anglo-SaxonsRead MoreBeowulf : An Epic Hero978 Words   |  4 Pages Beowulf is a character that exudes the qualities of an epic hero. Throughout this epic, Beowulf is seen as a hero to many and a major threat to the evils he encounters. The values of the Anglo-Saxons, who would have read and admired this poem, included loyalty, bravery, and honor. Beowulf’s character exemplifies all of these qualities to the highest degree. The values and traditions of the original composers of this story cause Beowulf’s character to be the perfect example of an Anglo-SaxonRead MoreBeowulf: an Epic Hero983 Words   |  4 PagesGauvain British Literature Beowulf Essay 9/22/04 Beowulf: An Epic Hero According to Abrams, the heroic poem is a long verse narrative on a serious subject, told in an elevated style, and centered on a heroic or quasi-divine figure on whose actions depends the fate of a tribe, a nation, or the human race. Beowulf fits Abrams description of an epic, exhibiting all of the characteristics listed throughout the book, thus defining Beowulf as a hero and making the book an epic through its elevatedRead MoreBeowulf, the Epic Hero1431 Words   |  6 PagesBeowulf, the Epic Hero There have been many grand stories about great warriors, and champions; those about epic heroes however, are the truly exceptional tales. 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