Laparoscopic Radical Prostatectomy with a Remote Controlled Robot.

PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Long-term analysis of oncological outcomes after laparoscopic radical cystectomy in Europe: results from a multicentre study by the European Association of Urology (EAU) section of Uro-technology.

OBJECTIVE: To report long-term outcomes of laparoscopic radical cystectomy (LRC) in a multicentre European cohort, and explore feasibility and safety of LRC. PATIENTS AND METHODS: This study was coordinated by European Association of Urology (EAU)-section of Uro-technology (ESUT) with nine centres enrolling 503 patients undergoing LRC for bladder cancer prospectively between 2000 and 2013. Data were retrospectively analysed. Descriptive statistics were used to explore peri- and postoperative characteristics of th ecohort. Kaplan-Meier curves were constructed to evaluate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Outcomes were also stratified according to tumour stage, lymph node (LN) involvement and surgical margin status. RESULTS: Minor complications (Clavien I-II) occurred in 39% and major (IIIa-IVb) in 17%. In all, 10 (2%) postoperative deaths were recorded. The median (interquartile, IQR) LN retrieval was 14 (9-17) and positive surgical margins were detected in 29 (5.8%) patients. The median (mean, IQR) follow-up was 50 (60, 19-90), during which 134 (27%) recurrences were detected. Actuarial RFS, CSS and OS rates were 66%, 75% and 62% at 5 years and 62%, 55%, 38% at 10 years. Significant differences in RFS, CSS and OS were found according to tumour stage, LN involvement and margin status (log-rank P < 0.001). On multivariate Cox analysis, T stage and LN involvement (both P < 0.001) were significant predictors of RFS, CSS and OS. Positive margins were significant predictors of RFS (P = 0.016) and CSS (P = 0.043). CONCLUSIONS: In this European LRC multicentre study, the largest to date, long-term RFS, CSS and OS rates after LRC appear comparable to those reported in current open RC series. Further randomised controlled trials are necessary to assess the global impact of LRC.

EAU policy on live surgery events.

CONTEXT: Live surgery is an important part of surgical education, with an increase in the number of live surgery events (LSEs) at meetings despite controversy about their real educational value, risks to patient safety, and conflicts of interest. OBJECTIVE: To provide a European Association of Urology (EAU) policy on LSEs to regulate their organisation during urologic meetings. EVIDENCE ACQUISITION: The project was carried out in phases: a systematic literature review generating key questions, surveys sent to Live Surgery Panel members, and Internet- and panel-based consensus finding using the Delphi process to agree on and formulate a policy. EVIDENCE SYNTHESIS: The EAU will endorse LSEs, provided that the EAU Code of Conduct for live surgery and all organisational requirements are followed. Outcome data must be submitted to an EAU Web-based registry and complications reported using the revised Martin criteria. Regular audits will take place to evaluate compliance as well as the educational role of live surgery. CONCLUSIONS: This policy represents the consensus view of an expert panel established to advise the EAU. The EAU recognises the educational role of live surgery and endorses live case demonstration at urologic meetings that are conducted within a clearly defined regulatory framework. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery. PATIENT SUMMARY: Controversy exists regarding the true educational value of live surgical demonstrations on patients at surgical meetings. An EAU committee of experts developed a policy on how best to conduct live surgery at urologic meetings. The key principle is to ensure safety for every patient, including a code of conduct and checklist for live surgery, specific rules for how the surgery is organised and performed, and how each patient's results are reported to the EAU. For detailed information, please visit www.uroweb.org.

Initial prostate biopsy: development and internal validation of a biopsy-specific nomogram based on the prostate cancer antigen 3 assay.

BACKGROUND: Urinary prostate cancer antigen 3 (PCA3) assay in combination with established clinical risk factors improves the identification of men at risk of harboring prostate cancer (PCa) at initial biopsy (IBX). OBJECTIVE: To develop and validate internally the first IBX-specific PCA3-based nomogram that allows an individual assessment of a man's risk of harboring any PCa and high-grade PCa (HGPCa). DESIGN, SETTING, AND PARTICIPANTS: Clinical and biopsy data including urinary PCA3 score of 692 referred IBX men at risk of PCa were collected within two prospective multi-institutional studies. INTERVENTION: IBX (≥ 10 biopsy cores) with standard risk factor assessment including prebiopsy urinary PCA3 measurement. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PCA3 assay cut-off thresholds were investigated. Regression coefficients of logistic risk factor analyses were used to construct specific sets of PCA3-based nomograms to predict any PCa and HGPCa at IBX. Accuracy estimates for the presence of any PCa and HGPCa were quantified using area under the curve of the receiver operator characteristic analysis and compared with a clinical model. Bootstrap resamples were used for internal validation. Decision curve analyses quantified the clinical net benefit related to the novel PCA3-based IBX nomogram versus the clinical model. RESULTS AND LIMITATIONS: Any PCa and HGPCa were diagnosed in 46% (n=318) and 20% (n=137), respectively. Age, prostate-specific antigen, digital rectal examination, prostate volume, and PCA3 were independent predictors of PCa at IBX (all p<0.001). The PCA3-based IBX nomograms significantly outperformed the clinical models without PCA3 (all p<0.001). Accuracy was increased by 4.5-7.1% related to PCA3 inclusion. When applying nomogram-derived PCa probability thresholds ≤ 30%, only a few patients with HGPCa (≤ 2%) will be missed while avoiding up to 55% of unnecessary biopsies. External validation of the PCA3-based IBX-specific nomogram is warranted. CONCLUSIONS: The internally validated PCA3-based IBX-specific nomogram outperforms a clinical prediction model without PCA3 for the prediction of any PCa, leading to the avoidance of unnecessary biopsies while missing only a few cases of HGPCa. Our findings support the concepts of a combination of novel markers with established clinical risk factors and the superiority of decision tools that are specific to a clinical scenario.

Laparoscopic partial nephrectomy: is it worth still performing the retroperitoneal route?

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190 ± 85 min versus 154 ± 47 (P = 0.001) and 9.2 ± 6.4 days versus 6.2 ± 4.5 days (P < 0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (P = 0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (P = 0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.

Neurophysiological testing to assess penile sensory nerve damage after radical prostatectomy.

INTRODUCTION: Radical prostatectomy (RP) can lead to erectile dysfunction due to surgical injury of the cavernous nerves. However, there is no simple, objective test to evaluate cavernous nerve damage caused by RP in clinical practice. AIM: To assess the value of the measurement of penile thermal and vibratory sensory thresholds to reflect cavernous nerve damage caused by RP. METHODS: We included 42 consecutive patients who underwent RP with cavernous nerve sparing (laparoscopic approach, N = 12) or without cavernous nerve sparing (laparoscopic, N = 13; retropubic, N = 11; or transperineal, N = 6). Penile thermal (warm and cold) and vibratory sensory thresholds were measured twice, together with the Erectile Dysfunction Symptom Score (EDSS), 1 month before and 2 months after RP. MAIN OUTCOME MEASURES: Penile sensory thresholds for warm, cold, and vibration sensations. RESULTS: Penile sensory thresholds for warm (P < 0.0001) and cold (P < 0.0001) sensations significantly increased after non-nerve-sparing RP, but not after nerve-sparing RP. Vibration threshold only increased after transperineal non-nerve-sparing RP (P = 0.031). EDSS values were significantly increased in all groups of patients 2 months after surgery. CONCLUSIONS: Sensory nerve fibers carrying penile skin sensations travel with the cavernous nerves in the pelvis. Therefore, testing these sensations may help to evaluate the extent of cavernous nerve damage caused by RP. In this series, post-operative changes in penile sensory thresholds differed with the surgical technique of RP, as the cavernous nerves were preserved or not. The present results support the value of quantitative penile sensory threshold measurement to indicate RP-induced cavernous nerve injury.

Modified supine percutaneous nephrolithotomy for large kidney and ureteral stones: technique and results.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the standard treatment for kidney stones >2cm. Recently, a novel approach in the modified supine lithotomy position has been developed. OBJECTIVE: To demonstrate with a video our technique of supine PCNL (sPCNL) and present our experience. DESIGN, SETTING, AND PARTICIPANTS: From September 2009 to August 2010, 47 consecutive patients were prospectively evaluated. There were 31 single, 9 multiple, and 7 staghorn stones. The mean body mass index was 26.1±5 (range: 17.3-45.7), the mean stone size was 29.6±15.3mm (range: 10-75), and patients' American Society of Anesthesiologists scores were 1, 2, and 3 in 31, 11, and 5 cases, respectively. SURGICAL PROCEDURE: Patients were positioned in Galdakao-modified supine Valdivia position. The details of the technique are shown in the film. MEASUREMENTS: Success was defined as patients free of stones or with residual stone fragments <4mm. RESULTS AND LIMITATIONS: Average operative room occupation time was 123.5±51.2min (range: 50-245). In the single, multiple, and staghorn stone groups, the immediate success rate after sPCNL was 90%, 78%, and 43%, respectively. Complications included one fever, two incidents of pyelonephritis, one renal colic, two urinary fistulae, one postoperative hemorrhage, and one incident of acute urinary retention. Mean hospital stay was 3.4±1.9 d (range: 2-12). Nine patients (19%) had a secondary procedure (extracorporeal shock wave lithotripsy or flexible ureterorenoscopy). At 3 mo, the success rate was 97%, 100%, and 100% in the single, multiple, and staghorn stone groups, respectively. However, the limitation of this study is its design, which is descriptive rather than comparative. CONCLUSIONS: sPCNL is a safe and reproducible method. It offers the advantage of simultaneous retrograde and antegrade endoscopic combined intrarenal surgery, and we believe it is a further advancement in stone management. In addition, it is easier from the anesthetist point of view than the traditional prone approach. In our hands, it meant a simplification of the operative technique, resulting in a more time-efficient procedure.

Fluoroscopy-guided renal access in supine percutaneous nephrolithotomy.

OBJECTIVE: To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). PATIENTS AND METHODS: From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. RESULTS: Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35-180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. CONCLUSIONS: This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.

Robot-assisted laparoscopic sacral colpopexy: initial experience in a high-volume laparoscopic reference center.

PURPOSE: To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center. PATIENT AND METHODS: 12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence. RESULTS: Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred. CONCLUSION: RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.

The prostate cancer gene 3 (PCA3) urine test in men with previous negative biopsies: does free-to-total prostate-specific antigen ratio influence the performance of the PCA3 score in predicting positive biopsies?

OBJECTIVE: to determine the performance characteristics of the prostate cancer gene 3 (PCA3) score on the outcome of biopsy relative to different ranges of free-to-total prostate-specific antigen (PSA) ratio (f/tPSA) in men with a previous negative biopsy and a PSA level of 2.5-10 ng/mL, as urine tests like PCA3 are currently under investigation in order to improve prostate cancer diagnosis and to decrease the rate of unnecessary rebiopsies. PATIENTS AND METHODS: data from the previous prospective European multicentre study were reviewed. Only patients with a PSA level of 2.5-10 ng/mL were included in the present study. In all, 301 patients had complete data. The diagnostic accuracy of the PCA3 score for predicting a positive biopsy outcome was studied using sensitivity, specificity, negative and positive predictive values. The PCA3 performance was evaluated relative to three different subgroups of f/tPSA, as follows: >20% (group 1), 10-20% (group 2) and <10% (group 3). RESULTS: the prostate cancer detection rates were 18.8%, 23.9% and 34.8% in groups 1, 2 and 3, respectively. The area under the receiver operating characteristic curve of the PCA3 score, total PSA and f/tPSA was 0.688, 0.553 and 0.571, respectively. The percentage of men with positive biopsies was 30.6%, 37.0% and 44.4% in those with a PCA3 score of >30, vs 10.3%, 15.5% and 28.6% when the PCA3 score was <30, in groups 1, 2 and 3, respectively. The difference was significant only in groups 1 and 2. In men with a f/tPSA of ≤ 10% the difference in detection rates relative to the PCA3 score was not statistically significant regardless of which PCA3 threshold was used. A high PCA3 score was significantly associated with age, clinical T2 stage and positive biopsy (P < 0.001, 0.013 and <0.001, respectively). In bivariate analysis accounting for the PCA3 score and the f/tPSA, a PCA3 score of >30 was a significant independent predictor of positive biopsies (odds ratio 3.01; 95% confidence interval 1.74-5.23; P < 0.001). CONCLUSIONS: PCA3 remained a better predictor of prostate cancer than f/tPSA. In men with a f/tPSA of >10%, the use of the PCA3 score was highly correlated with the risk of having cancer on re-biopsy, and could prevent unnecessary prostate biopsies if the value is low.

Intrafascial nerve-sparing radical prostatectomy with a laparoscopic robot-assisted extraperitoneal approach: early oncological and functional results.

OBJECTIVE: We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. METHODS: From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. RESULTS: The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. CONCLUSIONS: An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.

Prostate cancer gene 3 (PCA3): development and internal validation of a novel biopsy nomogram.

BACKGROUND: Urinary prostate cancer gene 3 (PCA3) represents a promising novel marker of prostate cancer detection. OBJECTIVE: To test whether urinary PCA3 assay improves prostate cancer (PCa) risk assessment and to construct a decision-making aid in a multi-institutional cohort with pre-prostate biopsy data. DESIGN, SETTING, AND PARTICIPANTS: PCA3 assay cut-off threshold analyses were followed by logistic regression models which used established predictors to assess PCa-risk at biopsy in a large multi-institutional data set of 809 men at risk of harboring PCa. MEASUREMENTS: Regression coefficients were used to construct four sets of nomograms. Predictive accuracy (PA) estimates of biopsy outcome predictions were quantified using the area under the curve of the receiver operator characteristic analysis in models with and without PCA3. Bootstrap resamples were used for internal validation and to reduce overfit bias. The extent of overestimation or underestimation of the observed PCa rate at biopsy was explored graphically using nonparametric loss-calibration plots. Differences in PA were tested using the Mantel-Haenszel test. Finally, nomogram-derived probability cut-offs were tested to assess the ability to identify patients with or without PCa. RESULTS AND LIMITATIONS: PCA3 was identified as a statistically independent risk factor of PCa at biopsy. Addition of a PCA3 assay improved bootstrap-corrected multivariate PA of the base model between 2% and 5%. The highest increment in PA resulted from a PCA3 assay cut-off threshold of 17, where a 5% gain in PA (from 0.68 to 0.73, p=0.04) was recorded. Nomogram probability-derived risk cut-off analyses further corroborate the superiority of the PCA3 nomogram over the base model. CONCLUSIONS: PCA3 fulfills the criteria for a novel marker capable of increasing PA of multivariate biopsy models. This novel PCA3-based nomogram better identifies men at risk of harboring PCa and assists in deciding whether further evaluation is necessary.

Laparoscopic radical prostatectomy after transurethral resection of the prostate: surgical and functional outcomes.

OBJECTIVES: To compare the morbidity and functional results after laparoscopic radical prostatectomy with and without previous transurethral resection of the prostate (TURP). METHODS: From May 1998 to January 2005, 640 patients underwent laparoscopic radical prostatectomy, of whom 46 (7.2%) had previously undergone TURP. The perioperative and postoperative data were compared between group 1 (with previous TURP) and group 2 (without previous TURP). The functional results were assessed by self-administered questionnaires at 12 and 24 months after surgery. RESULTS: In group 1, the operative time, hospital stay, and bladder catheterization duration was increased by 31 minutes, 1.9 days, and 2.9 days, respectively. The positive margin rate was not significantly different statistically between the two groups (P = .62). The 5-year actuarial freedom from biochemical recurrence rate was similar between the two groups (P = .86). Surgical complications occurred in 15.2% of group 1 and 5.7% of group 2 (P = .02). The risk of anastomotic stricture was 6.5% and 1.2% in groups 1 and 2, respectively (P = .02). Two years after surgery, the continence rate was 86.9% in group 1 and 95.8% in group 2 (P = .77), and the potency rate was 63.8% and 70.9%, respectively, after bilateral neurovascular bundle preservation (P = .61). However, neurovascular bundle preservation was performed after previous TURP in only 56.5% of group 1 vs 78.9% in group 2 (P = .02). The median follow-up was 50.8 months (range 30-107). CONCLUSIONS: Laparoscopic radical prostatectomy can be performed after TURP without compromising the oncologic results. However, patients should be informed that the procedure is associated with worse intraoperative and postoperative outcomes. Although the urinary continence rate was not hampered by previous TURP, neurovascular bundle preservation is technically more difficult and compromises postoperative erectile function.

Clinical utility of the PCA3 urine assay in European men scheduled for repeat biopsy.

BACKGROUND: The Prostate CAncer gene 3 (PCA3) assay has shown promise as an aid in prostate cancer (pCA) diagnosis in identifying men with a high probability of a positive (repeat) biopsy. OBJECTIVE: This study evaluated the clinical utility of the PROGENSA PCA3 assay. DESIGN, SETTING, AND PARTICIPANTS: This European prospective, multicentre study enrolled men with one or two negative biopsies scheduled for repeat biopsy. MEASUREMENTS: After digital rectal examination (DRE), first-catch urine was collected to measure PCA3 mRNA concentration and to calculate the PCA3 score. The PCA3 score was compared to biopsy outcome. The diagnostic accuracy of the PCA3 assay was compared to percent of free prostate-specific antigen (%fPSA). RESULTS AND LIMITATIONS: In 463 men, the positive repeat biopsy rate was 28%. The higher the PCA3 score, the greater the probability of a positive repeat biopsy. The PCA3 score (cut-off of 35) had a greater diagnostic accuracy than %fPSA (cut-off of 25%). The PCA3 score was independent of the number of previous biopsies, age, prostate volume, and total prostate-specific antigen (PSA) level. Moreover, the PCA3 score was significantly higher in men with high-grade prostate intraepithelial neoplasia (HGPIN) versus those without HGPIN, clinical stage T2 versus T1, Gleason score >or=7 versus <7, and "significant" versus "indolent" (clinical stage T1c, PSA density [PSAD] <0.15ng/ml, Gleason score in biopsy

Retroperitoneal laparoscopic radical nephrectomy: intermediate oncological results.

OBJECTIVES: To report the intermediate oncological results of laparoscopic radical nephrectomy by retroperitoneal approach. METHODS: From 1995 to 2006, 146 consecutive patients with removal of a malignant kidney tumor by laparoscopic retroperitoneal radical nephrectomy were analysed retrospectively. The patients were followed clinically, biologically and radiologically every 6 months. Disease-free survival and specific survival were determined among patients free of metastasis at surgery. RESULTS: Patient's average age was 61.1 years (25-85). The pathology of these cancers were: 108 clear cell carcinomas, 26 papillary carcinomas, 10 chromophobe carcinomas, and 2 miscellaneous. The T stage were: 105 pT1, 12 pT2, and 29 pT3 (TNM 2002). The Fuhrman grade were: I in 23 cases, II in 70 cases, III in 40 cases, and IV in 9 cases. The surgical margins were positive in 2. No port site recurrence occurred. The average follow-up was 35.4 months (1-137). Five patients had metastatic disease at presentation. Tumor progression was observed among 19 patients, in the form of a local (1) or remote recurrence (18). Fourteen patients died, including 7 because of their tumor. The disease-free survival at 5 and 10 years, were respectively 87.3 and 73.2%, and the cancer-specific survival were 96.2 and 92.0%, respectively. CONCLUSIONS: The laparoscopic retroperitoneal radical nephrectomy offers intermediate oncological results compatible with appropriate carcinological efficacy.

Tumor size does not predict risk of metastatic disease or prognosis of small renal cell carcinomas.

PURPOSE: We characterized the clinicopathological features and the prognosis of small solid renal tumors defined as tumors 4 cm or smaller. MATERIALS AND METHODS: We identified 1,208 patients who were treated with nephrectomy at 5 international academic centers for small solid renal tumors. Clinicopathological parameters and outcome data were collected for each patient and analyzed. RESULTS: Of the tumors 88% were renal cell carcinoma and 12% were benign. Of those with renal cell carcinoma 995 (93%) were localized (N0M0) and 72 (7%) presented with metastatic disease. Tumor size did not predict synchronous metastatic disease. The incidence of metastatic disease in the tumor size ranges 0.1 to 1.0, 1.1 to 2.0, 2.1 to 3.0 and 3.1 to 4.0 cm was 7%, 6%, 5% and 8%, respectively (p = 0.322). Survival rates were excellent. The majority of patients who died of renal cell carcinoma (54%) presented with synchronous metastatic disease, but 3% of patients with localized disease also died of renal cell carcinoma. In patients with localized disease there was a 7% chance of recurrence post nephrectomy at 5 years. Progression-free survival (28 months) was better than for patients with metastatic disease having a primary tumor greater than 4 cm (8 months). Tumor size was not retained as an independent prognostic factor of survival in multivariate analyses. The University of California Integrated Staging System and the Karakiewicz nomogram were the best predictors of cancer specific survival for all renal cell carcinoma stages (c-index 0.87). CONCLUSIONS: More than 85% of small solid renal tumors are renal cell carcinoma. The majority of localized small renal tumors can be cured with existing surgical approaches. However, there is a small but not insignificant risk of synchronous and metachronous metastatic disease and cancer associated death. Patients considering experimental therapies such as ablation and surveillance should be aware of this. Tumor size alone is not sufficient to distinguish renal cell carcinoma with benign behavior from aggressive small renal cell carcinoma. Survival of patients with small metastatic renal cell carcinoma is better then expected. The biology of these unique tumors should be further studied.

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications. METHODS: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression. RESULTS: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors. CONCLUSIONS: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.

Prognostic impact of tumor size on pT2 renal cell carcinoma: an international multicenter experience.

PURPOSE: The current tumor classification for renal cell carcinoma classifies pT2 tumors as larger than 7 cm in greatest dimension and limited to the kidney. We examined the current pT2 tumor classification of renal cell carcinoma and determined whether a tumor size cutoff exists that would improve prognostic accuracy. MATERIALS AND METHODS: We studied 706 patients with pT2 renal cell carcinoma treated with surgical extirpation at 9 international academic centers. Data collected from each patient included age at diagnosis, gender, 2002 TNM (tumor, node, metastasis) stage, tumor size, nuclear grade, performance status, histological subtype and disease specific survival. Disease specific survival was evaluated with univariate and multivariate analysis. RESULTS: Median followup was 52 months. Univariate Cox regression analysis showed a significant association of tumor size with disease specific survival (HR 1.11, p<0.001). An ideal tumor size cutoff of 11 cm was identified, which led to the stratification of 2 groups with respect to disease specific survival (p<0.0001) with 5 and 10-year survival rates of 73% and 65% for pT2 11 cm or less, and 57% and 49% for pT2 larger than 11 cm, respectively. The incidence of metastases was significantly greater in the larger than 11 cm group, while Eastern Cooperative Oncology Group performance status, Fuhrman grade and histological subtype were similar. Multivariate Cox regression analysis retained tumor size as an independent prognostic factor and as the strongest prognostic factor for patients with pT2N0M0 disease. CONCLUSIONS: Our data suggest that the current pT2 classification can be improved by subclassification into pT2a and pT2b based on a tumor size cutoff of 11 cm. Patients in the proposed pT2bN0M0 group are at higher risk for death from renal cell carcinoma and should be considered for adjuvant therapies. External validation is warranted before suggesting change to the TNM classification.

Prognostic relevance of tumour size in T3a renal cell carcinoma: a multicentre experience.

OBJECTIVE: To evaluate the prognostic role of tumour size in pathological stage T3a renal cell carcinoma (RCC) with fat invasion only and to assess whether this subgroup maintains its relevance over the other pathological stages. METHODS: We retrospectively studied 2113 patients from eight international institutions who were treated by surgical resection for T2-4 RCC. Disease-specific survival (DSS) was evaluated with univariate and multivariate analyses. RESULTS: Univariate analysis of patients with T3a RCC showed that tumour size was significantly associated with DSS (HR: 1.09, 95% CI: 1.05-1.12, p<0.001). An ideal cut-off of 7 cm for these patients was identified with a scatter plot of Martingale residuals and tumour size. The two T3a groups were distinctly different with respect to clinicopathologic parameters (performance status, metastases, grade, histological subtype) and survival (p<0.001). Median survival time was not reached for patients with T2 and T3a< or =7 cm disease with a 5- and 10-yr DSS rate of 70% and 59% and 63% and 53%, respectively. Median survival time for patients with T3a>7 cm, T3b, T3c, and T4 disease was 54, 46, 21, and 11 mo, respectively, with 5- and 10-yr DSS rates of 46% and 36%, 46% and 36%, 34% and 0%, and 16% and 14%, respectively. CONCLUSIONS: Our data indicate that tumour size is an important factor for predicting outcome of patients with T3a RCC with fat invasion only. Our findings should merit consideration during the next revision of the TNM classification.

Relationship between age at diagnosis and clinicopathologic features of renal cell carcinoma.

OBJECTIVES: To analyse the influence of age at diagnosis on tumour characteristics and cancer-specific survival in renal cell carcinoma (RCC). METHODS: Data on age, tumour characteristics, and survival for 4774 patients from 12 European RCC databases were recorded. Patients were divided into four groups according to age at diagnosis: < or =40, >40 and <60, > or =60 and <80, and > or =80 yr. The following variables were analysed: TNM stage, Fuhrman grade, tumour size, symptoms at diagnosis, ECOG performance status (PS), and cancer-specific survival. The groups were compared for usual clinical and pathologic variables, and cancer-specific survival. RESULTS: The four groups accounted for 288 (6%), 1839 (38.5%), 2499 (52.3%), and 148 cases (3.2%), respectively. Differences were found among groups for tumour stage, symptoms at diagnosis, ECOG PS, Fuhrman grade (p<0.001), tumour size, M stage, and histologic subtype (p: 0.02). Patients < or =40 yr were more likely to have papillary or chromophobe RCCs and less likely to have clear-cell RCCs. No significant difference was found among groups for N stage (p: 0.15). The 5-yr cancer-specific survival rates for the four age categories were 85%, 74%, 70%, and 69%, respectively. In multivariate analysis age category remained an independent prognostic parameter (p<0.001). CONCLUSIONS: Renal tumours diagnosed in younger age are characterized by lower tumour stages and grades as well as favourable histologic patterns compared with tumours in older patients. Basic research is required for explaining such a relationship between age, tumour aggressiveness, and therefore tumour biology.