Prospective longitudinal comparative study of early health-related quality-of-life outcomes in patients undergoing surgical treatment for localized prostate cancer: a short-term evaluation of five approaches from a single institution.

BACKGROUND AND PURPOSE: Quality of life (QoL) issues are a vital concern for the majority of patients seeking therapeutic intervention once they are found to have prostate cancer. A prospective longitudinal comparison using validated QoL instruments is a valuable technique to evaluate outcome differences. We evaluated the short-term QoL changes from baseline of five surgical approaches for localized prostate carcinoma delivered at a single institution. PATIENTS AND METHODS: A prospective longitudinal survey of 719 patients with newly diagnosed prostate cancer was initiated in 2001. The surgical procedures performed during this time period were open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), da Vinci robotic prostatectomy (dVP), (103)Pd brachytherapy ((103)Pd), and prostate cryoablation (PCryo). An Institutional Review Board-approved questionnaire comprised of validated QoL instruments (UCLA Prostate Cancer Index and American Urological Association Symptom Index [SI]) was mailed to enrolled patients prior to their selected surgery and again at 1, 3, 6, 9, 12, 18, 24, and 36 months after therapy. A percent of baseline score calculation including data from all five treatment cohorts for follow-up months 1, 3, and 6 was compared within groups. Group I consisted of patients undergoing ORP, LRP, or dVP. Group II consisted of patients undergoing (103)Pd or PCryo. RESULTS: Between January 2000 and April 2005, 498 patients (69%) were enrolled who completed the baseline questionnaire and at least one follow-up survey at 1, 3, or 6 months. The mean patient age at ORP, LRP, dVP, (103)Pd, and PCryo was 59, 61, 60, 67, and 72 years, respectively. Within Group I, early recovery of sexual function (at 3 months) appeared to occur sooner after dVP (35% return to baseline [RTB]) than ORP (24% RTB) and LRP (21% RTB) (P = 0.03). No other significant differences were noted, and trends toward improvement were seen in all groups. Within Group II, PCryo (18% RTB) had a more negative impact on sexual function at 3 months than did 103Pd (63% RTB) (P = 0.007), although a significant difference in baseline sexual function was also noted (P = 0.001). Early urinary function (at 1 month) was better after (103)Pd (82% RTB) than PCryo (72%) (P = 0.05), but this difference was lost at 6 months. In addition, the irritative and obstructive symptoms evaluated by the AUA SI were significantly worse (P = 0.003) at 3 months after (103)Pd than after PCryo. CONCLUSIONS: Different surgical approaches for the treatment of localized prostate cancer affect the shortterm QoL results in different ways. Urinary, sexual, and bowel function and bother are affected to a similar degree by ORP, LRP, and dVP. In an older population, the tissue destruction resulting from PCryo appears to relieve obstructive and irritative urinary symptoms but at the sacrifice of sexual function compared with (103)Pd.

Limitations of noncontrast CT for measuring ureteral stones.

BACKGROUND AND PURPOSE: Patients with renal colic are frequently evaluated in the emergency room with a helical noncontrast CT scan (NCCT) as the primary imaging modality. Treatment decisions are often based on the size of the ureteral stone(s). We wished to assess the accuracy of NCCT in estimating ureteral stone size compared with plain abdominal (KUB) films. PATIENTS AND METHODS: Forty-eight patients were identified who had ureteral stones seen on NCCT and KUB films performed on the same day. The number of consecutive images on which a ureteral stone was visible on NCCT was multiplied by the reconstruction interval of 5 mm to create a size estimate, which was compared with the measurements of the same stone seen on the KUB film. RESULTS: The NCCT overestimated stone size by approximately 30% to 50% compared with KUB. CONCLUSION: Counting the number of consecutive NCCT images depicting a ureteral stone is not an accurate method of stone measurement when a reconstruction interval of 5 mm is used. Urologists should consider stone measurement techniques carefully and understand the limitations of imaging studies when evaluating patients with symptomatic ureteral stones.

Laparoscopic pyeloplasty and flexible nephroscopy: simultaneous treatment of ureteropelvic junction obstruction and nephrolithiasis.

BACKGROUND AND OBJECTIVE: Ureteropelvic junction obstruction and concomitant calculus disease may coexist. Therapeutic controversy exists regarding their ideal management. We report our use of flexible nephroscopy during laparoscopic pyeloplasty for caliceal stone removal. METHODS: From August 1998 through May 2002, 50 laparoscopic pyeloplasties were performed. Seven patients had documented ureteropelvic junction obstruction and ipsilateral nephrolithiasis. Preoperative stone burden and location were assessed. After pyelotomy, a 16 Fr flexible endoscope was passed through the uppermost trocar under direct laparoscopic guidance into the collecting system. Stone extraction was performed with a 2.4 Fr Nitinol basket. Postoperative imaging was assessed. RESULTS: Complete stone-free status confirmed by postoperative imaging was achieved in 6 of 7 patients. The longest individual stone diameter ranged from 4 mm to 13 mm (mean, 10.3 mm), and an average of 2.5 stones per patient was removed (range, 1 to 4 stones). Neither intraoperative fluoroscopy nor lithotripsy was required. No intraoperative or delayed complications were noted during a mean follow-up of 8.5 months (range, 2 to 17 months). CONCLUSIONS: Laparoscopic pyeloplasty and concomitant flexible nephroscopy with basket extraction is a simple, attractive alternative for the simultaneous treatment of ureteropelvic junction obstruction presenting with coexisting nephrolithiasis. It appears more efficacious when the stone number is limited and diameters measure from 5 mm to 20 mm.

Hand-assisted laparoscopic removal of retroperitoneal liposarcoma.

Liposarcoma is known to be the most common soft-tissue sarcoma, and the treatment of retroperitoneal disease is surgical excision. We present a case of complete surgical removal with concomitant nephrectomy using a hand-assisted laparoscopic approach and provide a review of the published studies.

Modified running vesicourethral anastomosis after robotically assisted laparoscopic radical prostatectomy: use of solitary Lapra-Ty to secure posterior approximation.

OBJECTIVES: We describe a novel method of ensuring posterior approximation and preventing urinary leak during the running anastomosis of robotically assisted laparoscopic prostatectomy. METHODS: Two 3-0 Monocryl RB-1 sutures are tied end-to-end. The undyed suture is placed first at the 5-o'clock position on the bladder side outside-in and then through the urethra at the same location inside-out. Proceeding clockwise, the suture is placed twice more through both the bladder and the urethra. With gentle manipulation, the suture is cinched down to provide secure posterior approximation; however, if tension is released from the suture coming from the urethra, the approximation may loosen and could result in a potential "gap" and site for anastomotic leakage. To prevent potential loosening, tension is maintained on the stitch as a single Lapra-Ty is placed at the base of the suture as it leaves the urethra. When the tension is released, the posterior approximation is tightly maintained and the remaining anastomosis is completed. RESULTS: We have performed 110 robotically assisted laparoscopic prostatectomies. Six urinary leaks requiring prolonged catheterization were identified in our first 90 patients (6.7%). We have not experienced any urinary leakage or short-term complications in the subsequent 20 patients using this technique. CONCLUSIONS: We describe a novel technique to ensure secure posterior approximation during the vesicourethral anastomosis after robotically assisted laparoscopic prostatectomy. A single Lapra-Ty clip placed early during the anastomosis prevents potential "gaps" in the approximation that may be the source of troublesome leakage.

Estimation of acute blood loss in the anticoagulated rabbit model using 3 modalities of radio frequency energy ablation.

PURPOSE: An anticoagulated animal model was tested to evaluate estimated acute blood loss (EABL) following tissue ablation with 3 modalities of radio frequency (RF) thermal energy. MATERIALS AND METHODS: Four groups of randomly divided rabbits were established. Group 1 (3 control and 3 anticoagulated rabbits) underwent sham treatment (noRF), group 2 (2 control and 7 anticoagulated) received single probe dry RF (dRF) (475 KHz and 5 W for 2 minutes), group 3 (2 control and 7 anticoagulated) received single probe wet RF (wRF) (475 KHz with 14.6% hypertonic saline at 50 W for 40 seconds) and group 4 (3 control and 7 anticoagulated) was treated with vapor RF (vRF) (0.9% normal saline for 10 seconds). Oral warfarin sodium was the anticoagulant. Following a midline incision ablation was performed on the left kidney and liver. Pre-weighed gauze pads were used to collect EABL for a 5-minute observation period after needle probe removal. Temperature data were recorded from the right kidney using fiberoptic thermocouples. Lesions were grossly inspected and measured. RESULTS: Anticoagulation resulted in super anticoagulated animals with an average prothrombin time of almost 140 seconds. EABL was the least from the ablated left kidney for vRF (50 mg), followed by wRF (260 mg), dRF (390 mg) and noRF (1,800 mg). EABL was the least from the liver for vRF (10 mg), followed by wRF (470 mg), dRF (1,260 mg) and noRF (2,680 mg). A greater percent of total ablative time at 10 mm was spent at greater than 50C during wRF and vRF. Measured ablative lesions size was largest following vRF ablation. CONCLUSIONS: The thermal coagulative effects of RF ablation resulted in less bleeding compared with controls in this orally anticoagulated animal model. The novel RF modality vRF is introduced.