Alan McNeill

Western General Hospital, Edinburgh, Scotland, United Kingdom

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Publications (9)14.51 Total impact

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    ABSTRACT: Objectives:  Urologists are cautious to offer minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen (and therefore anticipated to have locally advanced or metastatic disease) because of concerns regarding lack of complete cure after minimally invasive radical prostatectomy and of worsening of continence if adjuvant radiotherapy is used. Methods:  A retrospective review of our institutional database was carried out to identify patients with PSA ≥20 ng/mL who underwent minimally invasive radical prostatectomy between January 2002 and October 2010. Intraoperative, pathological, functional and short-term oncological outcomes were assessed. Results:  Overall, 233 patients met study criteria and were included in the analysis. The median prostate-specific antigen and prostate size were 28.5 ng/mL and 47 mL, respectively. Intraoperative complications were the following: rectal injury (0.86%) and blood transfusion (1.7%). Early postoperative complications included prolonged (>6 days) catheterization (9.4%), hematoma (4.7%), deep venous thrombosis (0.86%) and lymphocele (5.1%). Late postoperative complications included cerebrovascular accident (0.4%) and anastomotic stricture (0.8%). Pathology revealed poorly differentiated cancer in 48.9%, pT3/pT4 disease in 55.8%, positive margins in 28.3% and lymph node disease in 20.2% of the cases. Adverse pathological findings were more frequent in patients with prostate-specific antigen >40 ng/mL and (or) in those with locally advanced disease (pT3/pT4). In 62.2% of the cases, adjuvant radiotherapy was used. At 1-year follow up, 80% of patients did not show evidence of biochemical recurrence and 98.8% of them had good recovery of continence. Conclusion:  Minimally invasive radical prostatectomy might represent a reasonable option in prostate cancer patients with high prostate-specific antigen as a part of a multimodality treatment approach.
    International Journal of Urology 07/2012; 19(10):923-7. · 1.73 Impact Factor
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    ABSTRACT: Current management options for low-stage malignant germ-cell testicular tumours after radical orchiectomy include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND). Open RPLND is the surgical gold standard but has a number of limitations. Firstly, approximately two-thirds of patients have either necrosis/fibrosis or pathologically negative nodes. Secondly, the operation results in a large scar and significant perioperative morbidity and convalescence. Laparoscopic retroperitoneal lymph node dissection has developed as a possible alternative to the open procedure. Currently, laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as a standard therapeutic option in the European Association of Urology (EAU) guidelines. L-RPLND has, however, proved to be an excellent staging tool ,which should be developed as a less invasive alternative to primary open RPLND. As a staging tool, L-RPLND is performed usually without retrocaval or retroaortic dissection and is used to determine pathological status. The therapeutic value of this more limited dissection is not known and currently trials are underway to establish the therapeutic benefits. L-RPLND has been reported as efficacious compared to open RPLND for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumours (NSGCT). The rate of tumour control after L-RPLND and the diagnostic accuracy of L-RPLND were equal to the open procedure, and the morbidity was significantly lower [1, 2]. Therefore, L-RPLND for stage I and low-volume retroperitoneal stage II disease may be performed at experienced urology centres as part of ongoing trials [3, 4]. Loss of antegrade ejaculation is the most common long-term problem that the young men who undergo this operation experience. In an attempt to minimise this problem, either a template dissection or nerve-sparing RPLND should be performed. In a right template dissection, the right postganglionic fibres are resected whilst the left side ones are left intact. This applies to the left side also. Complete unilateral resection of the nerves should not result in loss of antegrade ejaculation. Dissection of both sides is only required in bilateral RPLND.
    05/2011: pages 169-185;
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    ABSTRACT: In our series of 1,900 endoscopic extraperitoneal radical prostatectomies (EERPE) the incidence of symptomatic lymphocele following simultaneous pelvic lymph node dissection (PLND) is between 3 and 14% depending on the extent of lymph node dissection. We report the impact of bilateral peritoneal fenestration after completion of extraperitoneal prostatectomy and PLND on the incidence of lymphocele, postoperative pain and complications. A total of 100 consecutive patients undergoing EERPE and extended PLND were allocated into two groups. In Group A (n = 50) a 4-6 cm incision was performed bilaterally over the external iliac vessels down to the obturator fossa after completion of the main procedure. In Group B (n = 50) no peritoneal incisions were made. The postoperative assessment protocol included a visual analogue pain scale administered three times daily for 6 days, analgesia requirement, and ultrasound examination on 4th and 8th days, and 3 months postoperatively. CRP and leucocyte counts were measured on 1st and 2nd postoperative days. Complications were recorded according to our standard protocol using the Clavien classification. Three patients (6%) in Group A were found to have lymphoceles, none of which were symptomatic. Significantly more patients in Group B developed a lymphocele, (n = 16, 32%, P < 0.001) of which a significant number were symptomatic (n = 7, 14%, P < 0.001) and required laparoscopic fenestration. No significant difference was observed between the pain score in either group. Mean pain scores were 3.4 versus 3.8 at 6 h, and 0.8 versus 1.1 at 6 days, respectively. No difference in analgesia requirement, serum inflammatory markers and return to normal bowel activity was observed between the groups. This study demonstrates that peritoneal fenestration significantly reduces the incidence of both symptomatic and asymptomatic lymphocele, without an increase in postoperative morbidity. As symptomatic lymphocele is one of the most common complications of extraperitoneal PLND requiring reintervention, we recommend that peritoneal fenestration should be performed routinely after extraperitoneal radical prostatectomy and PLND.
    World Journal of Urology 09/2008; 26(6):581-6. · 2.89 Impact Factor
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    BJU International 05/2008; 101(7):909-28. · 3.05 Impact Factor
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    ABSTRACT: ObjectiveTraining in laparoscopy is still a challenge for the urologic community. Surgeons in training must learn the laparoscopic techniques, possibly without having ever performed the conventional procedure. In the present study, we provide a nonstructured literature review pertaining to laparoscopic training and discuss the training design and the modular concept.MethodsA thorough literature search was performed with the Medline database and different training procedures were analysed.ResultsDue to increasing time constraints, cost, stress, and ethical considerations, the modern operating room is not the ideal learning environment. Various simulators and models for laparoscopic training in urology and general surgery with different levels of validity and reliability are available. Wide acceptance of the use simulators has been hampered by the lack of standard and valid methods to measure and certify competence in basic psychomotor skills. Besides, it is unclear if trainees have enough access to these programmes and if they are sufficient enough to develop the required skills. Whether complex urologic procedures can be performed by beginners without open surgical expertise and whether experience in open surgery is definitely required before mastering laparoscopic techniques are still matters of issue.ConclusionThe lack of a standardised, evaluated training procedure needs to be overcome. Structured training programmes and transference of gained experience into daily practice are essential to provide urology with expert laparoscopists.
    EAU-EBU Update Series. 04/2007;
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    ABSTRACT: Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of laparoscopic (transperitoneal) RPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. Endoscopic extraperitoneal radical prostatectomy has many advantages but is not without complications. The aim of this review article is to describe the most common complications of this procedure. Complications associated with endoscopic extraperitoneal radical prostatectomy are: vascular injury--bleeding--haematoma, bowel injury, lymphocele, injury to the bladder--ureter, port site hernia, anastomotic leakage--stricture, obturator nerve injury--paralysis, gas embolism, catheter blockage, and miscellaneous like perineal pain, pubic osteitis, infection- urosepsis. The present review paper focuses on the identification and management of these complications The incidence of most complications directly correlates with the surgeons' experience, and the various complications are related to technical errors rather than to the technique itself. The laparoscopist performing endoscopic/ laparoscopic radical prostatectomy should be aware of all these complications. He should be able to recognise promptly, treat efficiently, and ideally prevent these complications.
    World Journal of Urology 01/2007; 24(6):668-75. · 2.89 Impact Factor
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    ABSTRACT: Relatively long learning curves and, therefore, initially longer operating times compared to conventional procedures are still a matter of debate. Today, there are numerous possibilities for learning laparoscopic techniques and establishing one's own laparoscopic programs, including various pelvitrainers and virtual reality computer programs. One useful and realistic way involves "wet lab" training programs for ablative and reconstructive procedures using the pig model. Today, laparoscopic urological surgery includes procedures with low (e.g. laparoscopy for undescended testicles), intermediate (laparoscopic pyeloplasty) and high level (laparoscopic/endoscopic prostatectomy) complexity. Therefore, laparoscopy should be an integral part of training in urology. A defined number of possibly multi-institutional training centers with well structured educational programs are needed. The main goal should be the standardization of surgical procedures as well as educational training programs in order to shorten individual learning curves and generate common quality standards.
    Der Urologe 10/2006; 45(9):1155-6, 1158-60, 1162. · 0.46 Impact Factor
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    ABSTRACT: We focus on the anaesthesiology and requirements for minimally invasive procedures for treating localized prostate cancer. The management of anaesthesia for laparoscopic and endoscopic radical prostatectomy (RP) can be more complex than expected. Numerous groups, especially early in their experience, have had problems (e.g. hypercarbia) with the anaesthesiology of the procedure. Co-operation between the surgeon and the anaesthesiologist is of paramount importance for a safe and effective laparoscopic or endoscopic RP. Nevertheless, the relative anaesthetic equipment and trained personnel should be available before embarking on such technically proficient procedures.
    BJU International 10/2006; 98(3):508-13. · 3.05 Impact Factor
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    ABSTRACT: Ein anhaltend diskutiertes Problem der laparoskopischen Operationen mit mittlerem und hohem Schwierigkeitsgrad sind die relativ langen Lernkurven und die damit verbundenen im Vergleich zur konventionellen Technik längeren Operationszeiten. Es gibt heute eine Vielzahl von Möglichkeiten, laparoskopische Operationstechniken zu erlernen. Diese Trainingsmöglichkeiten umfassen neben den sog. Pelvitrainern Computersysteme, die eine virtuelle Realität simulieren. Eine realistischere Methode stellen Übungen im sog. ,,wet lab“ dar, in dem am Schwein ablative und rekonstruktive Operationen trainiert werden können.Die Liste der Indikationen für laparoskopische Operationen in der Urologie umfasst heute Operationen mit einfachem (z. B. laparoskopische Hodensuche), mit mittlerem (laparoskopische Nierenbeckenplastik) bis hin zu Operationen mit hohem Schwierigkeitsgrad (laparoskopische/endoskopische Prostatektomie). Die Laparoskopie sollte deshalb ein fester Bestandteil der Ausbildung in unserem Fachgebiet sein. Dazu wird eine definierte Anzahl von Ausbildungszentren mit strukturierten Ausbildungsprogrammen, ggf. auch mit multizentrischen Kooperationen benötigt. Das Hauptziel unserer Bemühungen sollte in der Strukturierung und Standardisierung von Operationstechniken und Ausbildungsprogrammen liegen, um individuelle Lernkurven zu verkürzen und einheitliche Qualitätsstandards zu generieren.
    Der Urologe 01/2006; 45(9). · 0.46 Impact Factor