[Show abstract][Hide abstract] ABSTRACT: This study aimed at reviewing a contemporary series of patients who underwent robotic renal and adrenal surgery by a single surgeon at a tertiary referral academic medical center over a 6-year period, specifically focusing on the unique and serious complication of post-operative rhabdomyolysis of the dependent lower extremity. The cases of 315 consecutive patients who underwent robotic upper tract surgery over a 6-year period from August 2008 to June 2014 using a standardized patient positioning were reviewed and analyzed for patient characteristics and surgical variables that may be associated with the development of post-operative rhabdomyolysis. The incidence of post-operative rhabdomyolysis in our series was 3/315 (0.95 %). All three affected patients had undergone robotic nephroureterectomy. Those patients who developed rhabdomyolysis had significantly higher mean Body Mass Index, Charlson Comorbidity Index, and median length of stay than those who did not. The mean OR time in the rhabdomyolysis group was noted to be 52 min longer than the non-rhabdomyolysis group, though this value did not reach statistical significance. Given the trends of increasing obesity in the United States and abroad as well as the continued rise in robotic upper tract urologic surgeries, urologists need to be increasingly vigilant for recognizing the risk factors and early treatment of the unique complication of post-operative rhabdomyolysis.
Journal of Robotic Surgery 09/2015; 9(3):195-200. DOI:10.1007/s11701-015-0515-2
[Show abstract][Hide abstract] ABSTRACT: Use of the da Vinci® surgical robotic system has expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystostomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystostomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210-360 min), estimated blood loss was 50 mL (range: 50-75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystostomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.
[Show abstract][Hide abstract] ABSTRACT: Use of the da Vinci® surgical robotic systemhas expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystotomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystotomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210 - 360 min), estimated blood loss was 50 mL (range: 50 - 75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystotomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.
[Show abstract][Hide abstract] ABSTRACT: Introduction and Objectives: Rectovesical fistulas are a rare but devastating complication of radical prostatectomy. Management can be challenging due to deep location in the pelvis and recent surgery. We present a case of a patient whose prostatectomy was complicated by unrecognized rectal injury and pelvic abscess. After diverting colostomy, he was referred for management of the resulting rectovesical fistula. The patient failed primary closure with a sliding rectal advancement flap. Methods: In this video, we demonstrate robotic repair of a rectovesical fistula. The fistula tract was first dissected posterior to the bladder. Due to the location of the fistula, a transvesical approach was also required to identify the distal end of the fistula. Once the fistula was completely separated from the bladder, it was primarily closed. An omental flap was then mobilized and secured over the fistula site. Results: The patient underwent successful repair using minimally invasive techniques, preventing the morbidity of a large open procedure. The repair was confirmed with retrograde urethrogram and CT with rectal contrast. Conclusions: Robotic rectovesical fistula repair using a combined anterior and posterior approach is a useful technique to allow complete visualization of the fistula tract and adequate separation of the rectum and bladder. The addition of an omental flap decreases recurrence and facilitates healing of damaged tissues. Using minimally invasive techniques the patient spared a large open reconstruction. No competing financial interests exist. Runtime of video: 6 mins 56 secs
The Journal of Urology 04/2014; 191(4):e360. DOI:10.1016/j.juro.2014.02.1007 · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the effect of nerve sparing (NS) quality on self-reported patient urinary outcomes after radical prostatectomy.
A total of 102 preoperatively potent men underwent laparoscopic or robotic radical prostatectomy; NS was prospectively graded at surgery using a 0-4 scale/neurovascular bundle. Urinary functional outcomes were measured by validated Expanded Prostate Cancer Index Composite questionnaire at baseline and follow-up time points (1, 3, 6, 9, and 12 months) in 99 men who underwent various degrees of NS. Mixed linear regression was used to analyze the effect of NS quality and other clinical factors on urinary outcomes.
Patients with at least 1 neurovascular bundle spared completely, along with its supportive tissues (NS grade 4/4), noted significantly improved Expanded Prostate Cancer Index Composite urinary functional and continence outcomes as early as 1 month postoperatively and up to 12 months. Significantly less urinary bother was also noted in these men by 9-12 months postoperatively. Multivariate analysis revealed that bilateral or unilateral excellent NS (at least 1 bundle graded 4/4), increasing time from surgery, young patient age, and lower body mass index positively and significantly affected urinary functional outcomes, including pad use. Men who received excellent unilateral NS recovered urinary function about as well as men who had both neurovascular bundles spared in similar fashion.
The quality of NS significantly influences patient-defined urinary functional convalescence. Completely sparing at least 1 neurovascular bundle along with its supportive tissues has a dramatic effect on the recovery of urinary continence and quality of life in preoperatively potent men.
[Show abstract][Hide abstract] ABSTRACT: To review a multi-institutional series of robot-assisted nephroureterectomy (RANU) for management of upper urinary tract urothelial carcinoma (UUTUC) with respect to technique and perioperative outcomes.
Between May 2007 and July 2011, 43 RANU were performed at three institutions for UUTUC with review of perioperative outcomes. A three- or four-armed robotic technique was used in all cases based on surgeon preference and the entirety of all procedures was performed using the robot-assisted technique. Single and two robot-docking techniques are described.
The mean (range) operating time was 247 (128-390) min, blood loss was 131 (10-500) mL and the median (range) length of stay was 3 (2-87) days. Pathology was pTa in nine patients, pT1 in 14 patients, pT2 in three patients, pT3 in 15 patients and pT4 in two patients. Lymph node dissection was performed in 22 patients (51%) with a mean (range) lymph node count of 11 (4-23). There were six postoperative complications: bleeding requiring a blood transfusion (grade II), splenic bleeding (grade IV), two cases of pneumonia (grade II) and two cases of rhabdomyolysis (grades II and IV). Nine recurrences (six bladder, two within the retroperitoneum and one in the contralateral collecting system) have been found to date on routine surveillance with a mean follow-up of 9 months.
RANU is a feasible alternative to laparoscopic and open techniques. Particular steps of the operation including sutured closure of the cystotomy and regional lymphadenectomy are facilitated with the use of robot-assisted surgery. Long-term outcomes are necessary to assess the relative efficacy of these approaches to more established techniques; however, early perioperative outcomes appear promising.
BJU International 08/2013; 112(4):E295-300. DOI:10.1111/bju.12163 · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To clarify the role of phosphodiesterase type 5 (PDE5) inhibitors in post-prostatectomy penile rehabilitation (PPPR). To compare nightly and on-demand use of PDE5 inhibitors after nerve-sparing minimally invasive radical prostatectomy (RP).
We conducted a single-institution, double-blind, randomized controlled trial of nightly vs on-demand 50-mg sildenafil citrate after nerve-sparing minimally invasive RP. A total of 100 preoperatively potent men, aged <65 years, with scores on the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) ≥26, underwent nerve-sparing surgery. The patients were randomized to either nightly sildenafil and on-demand placebo (nightly sildenafil group), or on-demand sildenafil and nightly placebo (on-demand sildenafil group; maximum on-demand dose six tablets/month) for 12 months. Patients then underwent a 1-month washout period. Validated measures of erectile function (IIEF-EF score and the Expanded Prostate Cancer Index Composite [EPIC]) were compared between treatment groups over the entire 13-month time course, using multivariable mixed linear regression models.
The treatment groups were well matched preoperatively (mean age 54.3 vs 54.6 years, baseline IIEF-EF score 29.4 vs 29.3, for the nightly vs the on-demand sildenafil groups, respectively). No significant differences were found in erectile function between treatments (nightly vs on-demand sildenafil) at any single timepoint after RP, after adjusting for potential confounding factors. When evaluated over all timepoints simultaneously, no significant effects of treatment group (nightly vs on-demand sildenafil) were found on recovery of potency, as assessed by absolute IIEF-EF scores (P = 0.765), on percentage of men returning to an IIEF-EF score >21 (P = 0.830), or on IIEF-EF score recovery to a percentage of baseline value (P = 0.778). When evaluated over all timepoints simultaneously, no significant effects of treatment group were found on secondary endpoints such as assessment of potency (including EPIC item 59 response 'erections firm enough for intercourse'), attempted intercourse frequency or confidence.
Erectile recovery up to 1 year after RP does not differ between previously potent men who use sildenafil nightly compared to on-demand. This trial does not support chronic nightly sildenafil as being any better than on-demand sildenafil for use in penile rehabilitation after nerve-sparing minimally invasive RP.
BJU International 05/2013; 112(6). DOI:10.1111/bju.12253 · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Chemokines are involved in cancer-related inflammation and malignant progression. In this study, we evaluated expression of CCR8 and its natural cognate ligand CCL1 in patients with urothelial carcinomas of bladder and renal cell carcinomas.
We examined CCR8 expression in peripheral blood and tumor tissues from patients with bladder and renal carcinomas. CCR8-positive myeloid cells were isolated from cancer tissues with magnetic beads and tested in vitro for cytokine production and ability to modulate T-cell function.
We show that monocytic and granulocytic myeloid cell subsets in peripheral blood of patients with cancer with urothelial and renal carcinomas display increased expression of chemokine receptor CCR8. Upregulated expression of CCR8 is also detected within human cancer tissues and primarily limited to tumor-associated macrophages. When isolated, CD11b(+)CCR8(+) cell subset produces the highest levels of proinflammatory and proangiogenic factors among intratumoral CD11b myeloid cells. Tumor-infiltrating CD11b(+)CCR8(+) cells selectively display activated Stat3 and are capable of inducing FoxP3 expression in autologous T lymphocytes. Primary human tumors produce substantial amounts of the natural CCR8 ligand CCL1.
This study provides the first evidence that CCR8(+) myeloid cell subset is expanded in patients with cancer. Elevated secretion of CCL1 by tumors and increased presence of CCR8(+) myeloid cells in peripheral blood and cancer tissues indicate that CCL1/CCR8 axis is a component of cancer-related inflammation and may contribute to immune evasion. Obtained results also implicate that blockade of CCR8 signals may provide an attractive strategy for therapeutic intervention in human urothelial and renal cancers.
Clinical Cancer Research 01/2013; 19(7). DOI:10.1158/1078-0432.CCR-12-2091 · 8.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
During laparoscopic or robotic assisted laparoscopic prostatectomy, the surgeon lacks tactile feedback which can help him tailor the size of the excision. Ultrasound elastography (USE) is an emerging imaging technology which maps the stiffness of tissue. In the paper we are evaluating USE as a palpation equivalent tool for intraoperative image guided robotic assisted laparoscopic prostatectomy.
Two studies were performed: 1) A laparoscopic ultrasound probe was used in a comparative study of manual palpation versus USE in detecting tumor surrogates in synthetic and ex-vivo tissue phantoms; N=25 participants (students) were asked to provide the presence, size and depth of these simulated lesions, and 2) A standard ultrasound probe was used for the evaluation of USE on ex-vivo human prostate specimens (N=10 lesions in N=6 specimens) to differentiate hard versus soft lesions with pathology correlation. Results were validated by pathology findings, and also by in-vivo and ex-vivo MR imaging correlation.
In the comparative study, USE displayed higher accuracy and specificity in tumor detection (sensitivity=84%, specificity=74%). Tumor diameters and depths were better estimated using USE versus with manual palpation. USE also proved consistent in identification of lesions in ex-vivo prostate specimens; hard and soft, malignant and benign, central and peripheral.
USE is a strong candidate for assisting surgeons by providing palpation equivalent evaluation of the tumor location, boundaries and extra-capsular extension. The results encourage us to pursue further testing in the robotic laparoscopic environment.
Medical science monitor: international medical journal of experimental and clinical research 10/2012; 18(11):CR635-642. DOI:10.12659/MSM.883540 · 1.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This chapter reviews the surgical techniques and published studies relevant to optimization of oncologic and functional outcomes during laparoscopic and robot-assisted radical prostatectomy. Since 2000, several studies have addressed methods for reducing positive surgical margins to optimize oncologic outcomes as well as reducing the morbidities associated with laparoscopic (LRP) and robot-assisted (RALP) radical prostatectomy, namely erectile dysfunction and urinary incontinence. Studies addressing functional outcomes have provided new and important technical insights into potential mechanisms for optimizing the preservation of potency and continence. The techniques of LRP and RALP have continued to evolve with significant efforts made to optimize functional outcomes following surgery. In the quest for achieving the “trifecta” of cancer cure, urinary continence, and potency, published outcomes to date suggest that the former two goals appear to be reasonably well achieved in properly selected patients, while avoiding postoperative erectile dysfunction remains the most challenging.
Smith's Textbook of Endourology, 01/2012: pages 1135-1146; , ISBN: 9781444335545
[Show abstract][Hide abstract] ABSTRACT: Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
Few studies exist comparing functional outcomes between RALP and LRP using validated questionnaires.
This single surgeon study utilizes data from the EPIC questionnaire that was collected prospectively to compare urinary and sexual function after prostatectomy. In this comparison, return of post-prostatectomy continence was similar between groups while RALP patients demonstrated earlier return of sexual function.
BJU International 09/2011; 109(6):898-905. DOI:10.1111/j.1464-410X.2011.10551.x · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Renal cell carcinoma (RCC), the most common human kidney cancer, is frequently infiltrated with tumor-associated macrophages (TAM) that can promote malignant progression. Here, we show that TAMs isolated from human RCC produce substantial amounts of the proinflammatory chemokine CCL2 and immunosuppressive cytokine IL-10, in addition to enhanced eicosanoid production via an activated 15-lipoxygenase-2 (15-LOX2) pathway. TAMs isolated from RCC tumors had a high 15-LOX2 expression and secreted substantial amounts of 15(S)-hydroxyeicosatetraenoic acid, its major bioactive lipid product. Inhibition of lipoxygenase activity significantly reduced production of CCL2 and IL-10 by RCC TAMs. In addition, TAMs isolated from RCC were capable of inducing in T lymphocytes, the pivotal T regulatory cell transcription factor forkhead box P3 (FOXP3), and the inhibitory cytotoxic T-lymphocyte antigen 4 (CTLA-4) coreceptor. However, this TAM-mediated induction of FOXP3 and CTLA-4 in T cells was independent of lipoxygenase and could not be reversed by inhibiting lipoxygenase activity. Collectively, our results show that TAMs, often present in RCCs, display enhanced 15-LOX2 activity that contributes to RCC-related inflammation, immunosuppression, and malignant progression. Furthermore, we show that TAMs mediate the development of immune tolerance through both 15-LOX2-dependent and 15-LOX2-independent pathways. We propose that manipulating LOX-dependent arachidonic acid metabolism in the tumor microenvironment could offer new strategies to block cancer-related inflammation and immune escape in patients with RCC.
Cancer Research 09/2011; 71(20):6400-9. DOI:10.1158/0008-5472.CAN-11-1261 · 9.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Inadvertent bladder injury is a potential complication of various urological and pelvic surgeries. Bladder injury can also be a complication of natural orifice transluminal endoscopic surgery (NOTES). The aim of this study was to test the feasibility of a NOTES approach to repair bladder lacerations in a blinded porcine study.
Intentional bladder lacerations were made to mimic accidental injury during NOTES in 7 pigs. In 3 animals, the site of bladder injury was identified and repaired by a blinded endoscopist. Bladder laceration and transluminal access sites were closed with Endoclips. Leak test was performed to confirm adequate closure. Survival animals were monitored postoperatively and surgical sites were inspected for abscess, bleeding, or damage to surrounding structures at necropsy.
Complete endoscopic closure of bladder injuries was achieved in all 7 animals with a negative leak test. The site of laceration was successfully identified by the blinded endoscopist and repaired in all 3 animals in which it was attempted. Survival animals had an uneventful postoperative course without any complications.
This blinded feasibility study shows that urinary bladder injury occurring during NOTES can be successfully managed via a NOTES approach using currently available endoscopic accessories.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 07/2011; 15(3):285-90. DOI:10.4293/108680811X13071180407311 · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic nephroureterectomy is a well-established surgical treatment option for patients with transitional cell carcinoma
of the upper urinary tract and has well-published data supporting an advantage in decreased patient morbidity compared to
open techniques with similar oncologic outcomes. With the recent addition of the da Vinci Surgical System (Intuitive Surgical
Inc., Sunnyvale, CA), robot-assisted laparoscopic nephroureterectomy (RLNUx) may provide additional technical advantages to
the surgeon to further improve upon the outcomes noted with the conventional laparoscopic technique. This chapter provides
a detailed description of the RLNUx technique, its indications, contraindications, preoperative preparation, operative steps,
KeywordsLaparoscopy-Nephroureterectomy-Robotic surgery-Transitional cell carcinoma
Retroperitoneal Robotic and Laparoscopic Surgery, 02/2011: pages 89-96;
[Show abstract][Hide abstract] ABSTRACT: Outcome measures following radical prostatectomy are not standardized. Though excellent potency rates are widely reported, few studies address a return to baseline function. We analyze validated sexual health-related quality-of-life outcomes by a strict definition, a return to baseline function, and compare them to less stringent, yet more frequently referenced, categorical definitions of potency.
Patients undergoing laparoscopic radical prostatectomy from April 2001 to September 2007 completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaire at baseline and 3, 6, 12, and 24 months postoperatively. We defined a return to baseline as a recovery to greater than one-half standard deviation of the studied population below the patient's own baseline (clinically detectable threshold). We compared these outcomes to a categorical definition of potency involving intercourse frequency. To limit confounders, we performed subset analyses of preoperatively potent men who received bilateral nerve preservation. Factors predictive of return to baseline function were assessed in multivariable analysis.
A total of 568 patients met inclusion criteria. Mean age and follow-up were 57.2 years and 16.9 months, respectively. Using the categorical definition, 85% of preoperatively potent men with bilateral nerve preservation were "potent" at 24 months; however, only 27% returned to their baseline sexual function. In multivariable analyses baseline function, number of nerves spared, and age were independent predictors of a return to baseline function.
While most preoperatively potent men who receive bilateral nerve preservation engage in intercourse postoperatively, few return to their baseline sexual function. We believe that these data provide context for the expectations of patients who elect extirpative therapy.
World Journal of Urology 02/2011; 29(1):29-34. DOI:10.1007/s00345-010-0616-5 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Radical nephroureterectomy with formal bladder cuff excision was first proposed in 1933 by Kimball and Ferris (J Urol 31:
257, 1933) for the treatment of papillomatous tumors of the renal pelvis and ureter. This approach has become standard of
care for upper urinary tract neoplasms as many of these tumors are characterized by multifocality, high ipsilateral recurrence
rates after partial resection, and low (<5%) incidence of contralateral disease. In 1991, Clayman et al. first described a
laparoscopic approach to nephroureterectomy (Clayman RV, Kavoussi LR, Figenshau RS, Chandhoke PS, Albala DM, J Laparoendosc
Surg 1(6):343–349, 1991). A laparoscopic approach to upper tract neoplasm has become more prevalent with increasing evidence
supporting equivalent oncologic outcomes (Bariol SV, Stewart GD, McNeill SA, Tolley DA, J Urol 172(5):1805–1808, 2004; Muntener
M, Nielsen ME, Romero FR, Schaeffer EM, Allaf ME, Brito FA, Pavlovich CP, Kavoussi LR, Jarrett TW, Eur Urol 51:1639–1644,
2007; Capitanio U, Shariat SF, Isbarn H, Weizer A, Remzi M, Roscigno M, Kikuchi E, Raman JD, Bolenz C, Bensalah K, Koppie
TM, Kassouf W, Fernandez MI, Strobel P, Wheat J, Zigeuner R, Langner C, Waldert M, Oya M, Guo CC, Ng C, Montorsi F, Wood CG,
Margulis V, Karakieweicz PI, Eur Urol 56(1):1–9, 2009; Waldert M, Remzi M, Klinger HC, Mueller L, Marberger M, BJU Int 103(1):66–70,
2009; Berger A, Haber GP, Kamoi K, Aron M, Desai MM, Kauok JH, Gill IS, J Urol 180(3):849–854, 2008; Kawauchi A, Fujito A,
Ukimura O, Yoneda K, Mizutani Y, Miki T, J Urol 169(3):890–894, 2003; Stifelman MD, Hyman MJ, Shichman S, Sosa RE, J Endourol
15(4):391–395, 2001; McNeill SA, Chrisofos M, Tolley DA, BJU Int 86(6):619–623, 2000) and a faster convalescence (Stifelman
MD, Hyman MJ, Shichman S, Sosa RE, J Endourol 15(4):391–395, 2001; Gill IS, Sung GT, Hobart MG, Savage SJ, Meraney AM, Schweizer
DK, Klein EA, Novick AC, J Urol 164(5):1513–1522, 2000; Shalhav AL, Dunn MD, Portis AJ, Elbahnasy AM, McDougall EM, Clayman
RV, J Urol 163(4):1100–1104, 2000) as compared to open surgery. More recently, robot-assisted radical nephroureterectomy (RARNU)
has been described as an alternative to laparoscopic nephroureterectomy. RARNU offers the potential advantages of improved
surgeon efficiency in suturing, ergonomics, and ease of bladder reconstruction after bladder cuff excision without compromise
to oncologic efficacy (Park SY, Jeong W, Ham WS, Kim WT, Tha KH, BJU Int 104:June 10(11):1718–1721, 2009; Park SY, Jeong W,
Choi YD, Chung BH, Hong SJ, Rha KH, Yonsei Med J 49(6):897–900, 2008; Eun D, Bhandari A, Boris R, Rogers C, Bhandari M, Menon
M, BJU Int 100(5):1121–1125, 2007). In this chapter we describe the technique of robot-assisted laparoscopic nephroureterectomy.
Atlas of Robotic Urologic Surgery, 12/2010: pages 143-158;