Robotic Surgery Faster in Repairing Kidney Blockages

A comparison of two types of minimally invasive surgery to repair kidney blockages that prevent urine from draining normally to the bladder found that robot-assisted surgery was faster and resulted in less blood loss and shorter hospital stays.

Reporting in the Canadian Journal of Urology, Ashok Hemal, M.D., a urologic surgeon from Wake Forest University Baptist Medical Center, compared laparoscopic and robot-assisted surgery for repairing the blockage, known as uretero-pelvic junction obstruction. Following the patients for 18 months showed that both options were equally successful, but the robot-assisted technique had several advantages.

On average, robot-assisted surgery was 50 percent faster (98-minute versus 145-minute average), resulted in 60 percent less blood loss (40ml versus 101ml average), and required a two-day hospital stay, versus 3.5 days for laparoscopic surgery.

“This was one of the first studies where a single surgeon at one center performed both types of surgery and compared the results,” said Hemal, director of the Robotic and Minimally Invasive Urologic Surgery Program at Wake Forest Baptist. “It allows for a more accurate comparison of surgical options than multiple physicians performing the surgeries. The results showed that robot-assisted surgery had significant advantages for this condition. It is also generally easier for surgeons to learn.”

All 60 patients had a procedure known as pyeloplasty that involves reconstructing the narrow area where part of the kidney meets the ureter, the tube that carries the urine from the renal pelvis into the bladder. Blockages in this area can be the result of birth defects or, in adults, from injury, previous surgery or disorders that can cause inflammation of the upper urinary tract.

Previously the repair required a large incision. New technology led to minimally invasive approaches that require only small incisions — laparoscopic surgery, in which the surgeon directly manipulates a viewing device and operating instruments inserted into the abdomen, and robot-assisted surgery, in which the surgeon sits at a console and uses hand and finger movements to control centimeter-size instruments while viewing the surgical site on a screen.

Various studies have reported on the results of the options, but this is one of the first studies in which a surgeon with expertise in both options compared them. Hemal treated 30 patients with laparoscopic surgery and 30 with robot-assisted surgery.

“The evolution of laparoscopic surgery in urology has been limited because it is technically challenging and requires the surgeon to be proficient in advanced suturing,” said Hemal. “Robot-assisted surgery offers a way of overcoming some of the major impediments of laparoscopic surgery. This study shows the two options are equally effective and that robot-assisted surgery has several advantages.”

Hemal’s colleagues on the report are Satyadip Mukherjee, M.D., and Kaku Singh, M.D., both with the All India Institute of Medical Sciences in New Delhi, where the surgeries were performed.

Source: Canadian Journal of Uroloygy, Wake Forest University Baptist Medical Center (2/18/2010)

Knee and Hip Replacement Pain: A New Approach to Pain Management

Patients undergoing knee or hip replacements recover more quickly when treated with targeted pain-blocking medications that may eliminate the need for general anesthesia during surgery and intravenous narcotics drugs after surgery.

A decade ago, patients undergoing hip or knee replacements were almost exclusively given general anesthesia during surgery and intravenous narcotic pain medications afterward. This approach works for most people and still is commonly practiced. But both general anesthesia and intravenous narcotic drugs can cause nausea, vomiting, grogginess, decreased bowel function and other side effects.

In the early 2000s, Mayo Clinic anesthesiologists began developing new anesthesia protocols for joint replacement surgery that used known anesthetic and pain relief techniques in new combinations. Their goal was to eliminate the need for general anesthesia and intravenous narcotics and the resulting side effects.

The new procedures may vary but typically involve:

A choice: Even with the new protocols, patients may choose regional anesthesia, where the lower half of the body is numbed, or general anesthesia.

Oral pain medications early on: A combination of oral narcotic pain medications are given prior to surgery. Oral narcotics have fewer side effects than narcotics given intravenously. This technique is helpful for recovery whether general or regional anesthesia is used.

Sedation: Sedative drugs given before surgery help patients using regional anesthesia nap during the procedure, but not lose consciousness.

Nerve blocks: Through a catheter, a continuous infusion of numbing medicine is pumped near the surgery site for 48 hours. Nerve blocks are performed in conjunction with general or regional anesthesia.

Oral pain medications after surgery: For more than 95 percent of patients, pain that occurs after the nerve blocks are removed can be managed with oral pain medications such as acetaminophen (Tylenol, others), tramadol (Ultram, others) or oxycodone. Intravenous narcotic medications are used as a last resort.

Patients who receive regional anesthesia report significantly less pain after surgery than those receiving general anesthesia and intravenous narcotics. These patients are out of bed sooner, begin physical therapy sooner and leave the hospital one to two days before patients who were given general anesthesia and intravenous narcotics. With the newer protocols, patients may still experience typical side effects including nausea and vomiting, but to a lesser degree than with the older anesthesia methods.

Another benefit is that regional anesthesia protocols make surgery an option for older adults with more complicated conditions. A decade ago, older adults often were not considered candidates for surgery because they would have fared poorly with older anesthesia techniques.

Doctors report few downsides to these newer pain management approaches. Nerve injury is a rare potential complication. For most people, the regional anesthesia protocols are a change for the better, resulting in less pain, fewer complications and a quicker recovery.

Source: Mayo Clinic (2/10/2010)