- [Show abstract] [Hide abstract] ABSTRACT: Urologic tumors invading the inferior vena cava can be a difficult management problem. They are traditionally dealt with utilizing hypothermic circulatory arrest through central cannulation for cardiopulmonary bypass performed through a median sternotomy in addition to the large abdominal incision for the kidney tumor. We describe a single incision approach utilizing normothermic cardiopulmonary bypass to address this technical challenge.
- [Show abstract] [Hide abstract] ABSTRACT: Although open radical cystectomy (ORC) remains the gold-standard management of muscle-invasive bladder cancer, the number of centers performing robotic-assisted radical cystectomy (RARC) has recently increased, prompting greater oncological outcome concerns. Although limited in patient number and follow-up, short-term RARC data from centers of excellence appear to show the approach to be safe and effective, with improved perioperative and functional outcomes, while maintaining comparable oncologic efficiency. Nevertheless, despite the surge of centers adopting RARC, the long-term effectiveness of minimally-invasive techniques has yet to be proven. This review of published RARC series affirms the need for prospective, long-term, controlled studies to adequately evaluate the role of robotics in bladder cancer surgery.
- [Show abstract] [Hide abstract] ABSTRACT: Obesity is becoming an increasing problem and is associated with increased incidence of renal-cell carcinoma. We sought to assess the impact of obesity on outcomes of laparoscopic partial nephrectomy for renal masses. We retrospectively reviewed the pathologic and clinical outcomes from January 2004 through August 2010 of consecutive partial nephrectomies that were performed at a single institution. Patients were segregated according to preoperative body mass index (BMI), and outcomes were compared. Seventy-eight nonobese (BMI<30), 24 obese (BMI 30-35), and 24 morbidly obese (BMI>35) patients were identified. Obese patients were significantly more likely to be female (66% >35 vs 32% <30). Other baseline characteristics were similar. There was a significant relationship between estimated blood loss (P=0.03) and increasing BMI when compared as a trend. No significant differences were observed in regard to operative time, transfusion rate, complications, or surgical margin status between groups. Laparoscopic partial nephrectomy can be safely performed in obese patients without significant expected difference in outcomes.
- [Show abstract] [Hide abstract] ABSTRACT: Patients with Gleason (GL) 6 prostate cancer in one or two biopsy cores can be upgraded and/or upstaged at the time of surgery, which may adversely impact long-term outcome. A novel model for prediction of adverse pathologic outcomes was developed using preoperative characteristics. Between 2003 and 2007, 1159 patients underwent robot-assisted radical prostatectomy (RARP) at our institution. GL 6 prostate cancer in one or two biopsy cores was identified in 416 (36%) patients. Logistic regression analyses were used to assess the rate of GL ≥7 and/or extraprostatic extension at RARP. Covariates consisted of age, body mass index (BMI), number of positive cores, greatest percent of cancer in a core (GPC), clinical stage, and preoperative prostate-specific antigen (PSA) level. After backward variable selection, the developed model was internally validated using the area under the curve and subjected to methods of calibration. Respectively, 278 (67%) and 138 (33%) patients had one or two positive biopsy cores. At RARP, 90 (22%) patients were upgraded to GL ≥7 and 37 (9%) had extraprostatic extension. The novel model relied on age, BMI, preoperative PSA level, and GPC for prediction of adverse pathologic outcomes and was 69% accurate. Calibration plot revealed a virtually perfect relationship between predicted and observed probabilities. In patients with GL 6 prostate cancer in one or two biopsy cores, 25% have more ominous pathology at RARP. The model provides an individual assessment of adverse outcomes at surgery. Consequently, it may be considered when counseling patients regarding their management options.
- [Show abstract] [Hide abstract] ABSTRACT: Current robot-assisted radical prostatectomy (RARP) data suggest comparable and, perhaps, improved pathologic outcomes when compared with laparoscopic and open techniques. In mature RARP series, overall positive surgical margin (PSM) rates have ranged between 9 and 19%. Independent risk factors for PSMs include lower surgeon case volume, pathologic stage and Gleason sum, lower prostate weight, higher pre-operative PSA level, and PSA density. Other possible prognostic indicators include biopsy Gleason sum, body mass index, and neurovascular bundle preservation. Various surgical techniques and tailoring nerve preservation based on disease severity appear to improve cancer control during RARP. The most common locations for PSMs during RARP are posterolateral and apical, but location and number do not appear to impact recurrence. An extensive PSM, however, does appear to be an adverse prognostic finding. Short- and mid-term biochemical recurrence-free survival appears equivalent for robotic, laparoscopic, and open radical prostatectomy. Unfortunately, the RARP data are too immature to estimate cancer-specific and overall survival.
- [Show abstract] [Hide abstract] ABSTRACT: Energy-based hemostasis of the prostatic vascular pedicles (PVP) during robot-assisted radical prostatectomy (RARP) may cause collateral thermal injury to adjacent neural tissue and has been shown to negatively impact sexual function recovery. The unique engineering design of the EnSeal(®) (Ethicon, Cincinnati, OH) has been demonstrated to limit collateral thermal tissue damage to <1.0 mm. Use of tissue and instrument cooling before and during device activation may potentially further reduce thermal spread. As such, we sought to evaluate the collateral tissue effects of EnSeal with or without cold saline irrigation (CSI) during PVP control. The EnSeal Trio device was used for PVP control in 20 consecutive men undergoing bilateral, non-nerve-sparing RARP. Ipsilateral vascular pedicles were randomly selected to EnSeal plus CSI (<4 °C) application to the tissue before and during device activation or EnSeal alone. The primary end point was the distance of thermal injury from the inked margin using both hematoxylin and eosin (H&E) and terminal transferase uridyl nick end-labeling (TUNEL) apoptosis staining. A mean of three measurements was taken for each pedicle. Pathologic analysis was performed by a single, blinded uropathologist. Mean distance of thermal injury from the inked margin using H&E staining was 0.31 mm (range 0.15-0.40 mm) and 0.98 mm (range 0.7-1.2 mm) for the EnSeal plus CSI and EnSeal alone, respectively (P < 0.0001). TUNEL staining also demonstrated lateral tissue damage of 0.39 mm (range 0.2-0.5 mm) and 1.12 mm (range 0.9-1.3 mm), respectively (P < 0.001). No complications related to hemostasis or postoperative bleeding were observed in the study. The hemostatic properties of EnSeal work effectively when submerged in CSI. Adjacent thermal tissue damage is significantly minimized with the addition of CSI. This may have a beneficial impact on nerve preservation and sexual function outcomes after RARP.
- [Show abstract] [Hide abstract] ABSTRACT: To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.
- [Show abstract] [Hide abstract] ABSTRACT: To describe genitourinary (GU) toxicity in men with a history of transurethral resection of the prostate (TURP) treated with external beam radiation therapy (EBRT) for prostate cancer. Seventy-one men with a history of TURP were treated with EBRT for prostate cancer. The median time from TURP to EBRT was 15 months. The median EBRT dose was 70 Gy, and 21 men (30%) received androgen deprivation therapy (ADT). Acute GU toxicity and late GU toxicity were scored by Radiation Therapy Oncology Group criteria and compared with a cohort of 538 men without prior TURP. The median follow-up for men with TURP and men without TURP was 40 months and 50 months, respectively (p = 0.7605). The rate of acute Grade 2 GU toxicity or higher was 41%, and was increased with a history of more than 1 TURP (73% vs. 31%, p = 0.0036). The 4-year rate of freedom from late Grade 3 GU toxicity or higher was 84%, and was decreased with ADT (45% vs. 95% without ADT, p = 0.0024). By last follow-up, maximal GU toxicity tended to resolve (p < 0.0001) and there was no worsening of urinary symptom scores (p = 0.6911). Compared to men without a prior TURP, TURP patients had a lower rate of freedom from late Grade 3 toxicity or higher (84% vs. 96%, p = 0.0483). Multivariate analysis suggested a higher rate of late Grade 3 toxicity or higher with TURP (risk ratio, 2.87; p = 0.0612) and EBRT dose of 74 Gy or greater (risk ratio, 2.26; p = 0.0521). Men treated for prostate cancer with EBRT after TURP have a higher risk of severe GU toxicity; however, the overall incidence is low, and toxicity tends not to persist.
- [Show abstract] [Hide abstract] ABSTRACT: To present outcomes of a contemporary series of patients undergoing radical cystectomy (RC) for bladder cancer after previous treatment for localized cancer of the prostate (CaP). A retrospective review of more than 1000 RCs performed for bladder cancer between 1995 and 2008 identified 49 patients previously treated for localized CaP. Patients were stratified according to the type of primary therapy received for CaP: any form of primary or adjuvant radiotherapy (brachytherapy or external beam radiotherapy) versus radical prostatectomy (RP) monotherapy. Perioperative data were analyzed and compared between the 2 groups. Of 49 patients, 40 (82%) underwent primary or adjuvant radiotherapy and 9 (18%) RP alone. Eleven (22%) patients received a continent diversion. Mean estimated blood loss (EBL) and hospital stay were 979 mL and 12 days, respectively. Extravesical disease (≥pT3a) was present in 23 patients (57.5%) in the radiotherapy group and in 2 patients (22%) in the RP group. Ten patients (all in the radiotherapy group) had a positive margin, 9 (90%) of whom had pathologic T4 disease. The overall major perioperative complication rate was 41%. Of the 6 patients with an ONB (all after RP), 4 had severe incontinence. Patients undergoing RC after previous treatment for localized CaP are at increased risk for perioperative morbidity. Patients should be counseled that orthotopic diversion after RP may be associated with significant incontinence. Extravesical disease is more prevalent in patients treated with previous radiation. We observed a high rate of positive margins associated with pathologic T4 disease in this cohort.
- [Show abstract] [Hide abstract] ABSTRACT: Angioembolization is often the first-line treatment for patients with renal angiomyolipoma (AML). Regrowth and repeated hemorrhage after embolization, however, remain a concern. Laparoscopic partial nephrectomy (LPN) is the definitive, minimally invasive treatment alternative. We compared the outcomes of LPN in patients who had a diagnosis of AML with patients with other renal tumors. From a prospective LPN database, we identified patients with a final pathologic diagnosis of AML (group 1). The ability of preoperative imaging to predict AML final pathology results was studied. Surgical and postoperative outcomes in group 1 were compared with the outcomes of the rest of our LPN cohort (group 2). Of 184 LPNs that were performed between 2002 and 2008, 14 (7.6%) patients and 15 renal units had a diagnosis of AML. Two patients underwent concomitant LPN and radiofrequency ablation (RFA) for multiple AML lesions. In group 1, only 33% of the patients had a preoperative diagnosis of AML. There were no significant differences in tumor size, age, preoperative estimated creatinine clearance, body mass index, and comorbidities between the groups. The mean estimated blood loss in groups 1 and 2 was 214 mL and 178 mL, respectively (P = 0.5). The complication rates were similar between the groups. With a median follow-up of 15 months, no AML recurrences or bleeding was observed in group 1. The results of LPN or RFA, when appropriate, in AML patients are comparable to the results of LPN for other renal tumors. The preoperative imaging studies were a poor predictor of AML in patients who were undergoing LPN.
- [Show abstract] [Hide abstract] ABSTRACT: The objective of this study was to compare the outcomes of patients >or=70 years of age undergoing laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN), and laparoscopic ablative techniques (LAT) for small renal masses. From a prospectively maintained database we identified 19 (LRN), 28 (LPN), and 19 (LAT) patients aged >or=70 who underwent surgery for cT1aN0M0 lesions. Perioperative, surgical, and functional outcomes were compared. The three groups were similar in age, race, body mass index, and estimated creatinine clearance. In the LRN group, mean tumor diameter was larger (3.3 vs. 2.4 cm [LPN] and 2.7 cm [LAT]; p = 0.0005) and there was a higher percentage of central tumors (73.7% vs. 25.0% and 5.3%; p < 0.0005) when compared with the LPN and LAT groups, respectively. Although intraoperative and postoperative complication rates were similar, mean estimated blood loss and operative time were highest in the LPN group (p < 0.05). Moreover, 42.1%, 39.3%, and 42.1% of patients had preoperative stage 3 chronic kidney disease in the LRN, LPN, and LAT groups, respectively. Patients who underwent LRN had a lower follow-up estimated creatinine clearance (43.4 vs. 61.4 mL/min [LPN] and 59.2 [LAT]; p < 0.01) and a higher likelihood of developing stage 3 chronic kidney disease after treatment (100% vs. 25.0% [LPN] vs. 18.2 [LAT]; p < 0.0005). Impaired renal function is common in elderly patients presenting with renal masses. LPN and LAT provide superior preservation of renal function when compared with LRN in this population. In appropriately selected patients >or=70 years of age presenting with T1a renal lesions, laparoscopic nephron-sparing approaches should be considered.
- [Show abstract] [Hide abstract] ABSTRACT: To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.
- [Show abstract] [Hide abstract] ABSTRACT: To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.
- [Show abstract] [Hide abstract] ABSTRACT: Therapy (case series) Level of Evidence 4. To investigate the outcomes of laparoscopic partial nephrectomy (LPN) for endophytic tumours and those located near the hilum or the posterior upper-pole, as these pose a technical challenge. Technically challenging tumours were defined as endophytic, hilar, or at the posterior upper-pole (group 1), and were compared to tumours in other locations (group 2). We collected data prospectively for all patients undergoing LPN at our institution, including baseline patient and tumour characteristics, surgical and postoperative outcomes. Two-sided t-test or rank-sum test, and chi-square or exact tests were used as appropriate for comparison of continuous and categorical variables, respectively, with P < 0.05 considered to indicate statistical significance. There were 184 patients treated with LPN (42 in group 1 and 142 in group 2) between 2002 and 2008 by one surgeon (A.L.S.). Groups 1 and 2 were similar in terms of baseline variables (age, sex, body mass index, comorbidities, previous surgery, renal function and haematocrit) and in tumour size. LPN for challenging tumours resulted in a higher rate of collecting system repair (78% in group 1, 61% in group 2, P = 0.03). However, operative (surgery time, warm ischaemia time, blood loss, intraoperative complications) and postoperative outcomes (renal function, nadir haematocrit, complication rate, hospital stay and positive margin rate) were similar between the groups. With developing experience LPN can be safe for technically challenging renal tumours in well selected patients.
- [Show abstract] [Hide abstract] ABSTRACT: Little is known about the health related quality of life of women who have undergone continent urinary diversion. We compared health related quality of life outcomes for women who underwent radical cystectomy with an orthotopic neobladder or Indiana pouch. From 1995 to June 2008 a single surgeon (GDS) performed radical cystectomy with an orthotopic neobladder in 47 women and radical cystectomy with an Indiana pouch in 45. A comprehensive database provided clinical, pathological and outcomes data. The validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index was mailed to 92 patients. Complete data were available for 87% of patients treated with radical cystectomy with an orthotopic neobladder and 93% of those treated with radical cystectomy with an Indiana pouch, with a median followup of 34 and 24 months, respectively (p = 0.8). Median (IQR) age was 65 (58, 71) and 61.5 (51, 67) years for patients with an orthotopic neobladder and Indiana pouch, respectively (p = 0.03). No significant differences were found for pathological stage, nodal status, blood loss, Clavien grade III or greater complications, adjuvant therapy or hospital stay between the 2 treatment groups, or between respondents and nonrespondents. Five-year survival rates for patients with an orthotopic neobladder and Indiana pouch were 65% and 58%, respectively (p = 0.9). There were 21 (75%) living patients with an orthotopic neobladder and 19 (61%) with an Indiana pouch who completed the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index, and physical (p = 0.53), social (p = 0.97), emotional (p = 0.61), functional (p = 0.55) and radical cystectomy specific (p = 0.54) health related quality of life domains were not significantly different between the groups. Women undergoing radical cystectomy with an orthotopic neobladder vs an Indiana pouch have similar health related quality of life outcomes. Larger series with longer followup and multiple surgeons are necessary to confirm these findings.
- [Show abstract] [Hide abstract] ABSTRACT: To propose a strict and specific definition of continence (leak-free and pad-free [LFPF]) and apply it to robot-assisted radical prostatectomy (RARP) outcomes on the basis of University of California-Los Angeles-Prostate Cancer Index (UCLA-PCI), as postprostatectomy incontinence is not well defined. A single-institution RARP database was reviewed concerning continence variables prospectively recorded by the UCLA-PCI. Specific responses to urinary function and continence items were reviewed at baseline and 1, 3, 6, 12, and 24 months after surgery. From February 2003 to September 2007, a total of 1005 of 1500 RARP patients had data available for review. At baseline, only 73% of these patients were LFPF. This decreased to 4%, 9%, 17%, 24%, and 28% at 1, 3, 6, 12, and 24 months after surgery, respectively. Applying less strict definitions, at 24 months, 68% of patients reported no pad use and 90% of patients reported no pad use or the use of a security pad. When stratified by baseline LFPF status, patients not LFPF at baseline had higher baseline international prostate symptom score scores, lower urinary function scores, lower urinary bother scores, and larger prostate weights. Patients LFPF at baseline disproportionately regained LFPF continence starting 6 months after surgery compared with those not LFPF at baseline: 20% vs 9% (P = .005), 27% vs 15% (P = .0009), and 33% vs 15% (P = .0146) at 6, 12, and 24 months, respectively. A strict definition of urinary continence results in more conservative postoperative outcomes. Preoperative LFPF status can be predictive of postoperative LFPF continence. However, only one-third of patients LFPF at baseline returned to LFPF at 24 months.
- [Show abstract] [Hide abstract] ABSTRACT: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p <or= 0.001; 266, 190, 169 ml; p <or=0.001). Positive surgical margin (PSM) rate decreased in pT2 patients (15% versus 10% versus 7%; p = 0.03) despite operating on men with higher grade disease (biopsy GS>or=7 in 24%, 40%, 44%; p <or= 0.001). At 12 months postRARP, pad free continence rate was 81% when self reported and 62% when assessed by the UCLA-PCI-SF36v2 questionnaire in the initial group. Continence rates improved to 93% and 75%, respectively, for cases 501-700 (p <or= 0.05). Furthermore, significant improvement in continence rates between consecutive case groups was observed at all postoperative time points. Potency rate was 83% (bilateral nerve preservation) and 56% (unilateral nerve preservation) at 12 months when self reported and 63% and 37% respectively by the UCLA-PCI-SF36v2. No significant differences in sexual function were noted with increased experience. A prolonged learning curve is observed for EBL, OT and pT2-PSM. In addition, to the best of our knowledge, this is first series demonstrating a continued improvement in urinary continence with increased RARP experience.
Article: Editorial comment.
The University of Chicago Medical Center
Chicago, IL, United States
- Department of Surgery
University of California, Davis
Davis, CA, United States
- Department of Urology