Impact of renal lesion size on perioperative and pathologic outcomes in patients undergoing laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The size of renal lesions managed with laparoscopic partial nephrectomy (LPN) has been increasing, especially as surgical volume and experience matures. The objective of this study was to assess the perioperative and pathologic outcomes of LPN when stratifying for size of renal lesion. PATIENTS AND METHODS: A retrospective review of LPN performed at the University of Chicago by a single surgeon (ALS) between October 2002 to July 2007 was performed. Patients (153) were then stratified into three groups according to radiographic diameter of the lesion: < or = 2 cm (group A), 2 to 4 cm (group B), and > or = 4 cm (group C). Perioperative, operative, and pathologic data were compared using analysis of variance and Pearson test. Moreover, serum creatinine and creatinine clearance (Cockcroft-Gault) were assessed postoperatively. RESULTS: With regard to operative parameters, operative time was significantly longer in renal lesions > 2 cm (P = 0.0012), and the need for collecting system repair was also more prevalent as lesion size increased (P < 0.0001). Warm ischemia time was longest with lesions 2 to 4 cm (35.3 min) compared with masses < or = 2 cm (27.2 min; P < 0.001) or > or = 4 cm (30.3 min; P = 0.028). All other variables were similar among the three groups, including the rates of positive surgical margins, complications, estimated blood loss, conversion, and transfusion. Comparison of pathologic data suggests smaller lesions are more likely to be of lower grade compared with larger lesions. Postoperative renal function did not differ among the groups with a mean follow-up of 19.9 months. CONCLUSIONS: Although LPN for renal masses 2 to 4 cm necessitated longer warm ischemia, short-term postoperative renal function was not affected by lesion size. Differences in warm ischemia time cannot be attributed solely to lesion size but are likely influenced by a combination of tumor size, location, and depth. LPN can be performed safely in selected patients with larger renal lesions.

Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: complete intracorporeal--initial case report.

INTRODUCTION: To the best of our knowledge, we report the first case of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric patient, outlining the surgical technique and short-term results. TECHNICAL CONSIDERATIONS: The operative steps of the open procedure were replicated laparoscopically using robotic-assistance. In brief, 5 transperitoneal laparoscopic ports were placed before docking the da Vinci S robotic system. A 20-cm ileal segment was isolated, and the gastrointestinal anastomosis was performed in an end-to-end fashion using intracorporeal suturing. The appendix was anastomosed to the right posterior wall of the bladder over an 8F feeding tube in an extravesical fashion. The bladder was incised in a coronal plane, and the simple ileal on-lay patch was anastomosed to the posterior and anterior walls of the bladder. A suprapubic catheter and pelvic drain were placed, and the Mitrofanoff stoma was then fashioned. Cystography was performed at 4 weeks postoperatively. CONCLUSIONS: This preliminary first successful report suggests that robotic-assisted ileocystoplasty and appendicovesicostomy is feasible. A reasonable outcome with early recovery, resumption of normal activities, and excellent cosmesis can be achieved in selected patients. However, whether a robotic-assisted approach provides any significant advantages over conventional open procedures is yet to be determined with a large case series.

Laparoscopic port-site metastasis in urologic surgery.

PURPOSE: Port-site metastasis has been an increasing concern with the spread of laparoscopy in managing urologic malignancies. The purpose of this study was to provide a current review of port-site metastases reported in the urologic oncology literature, as well as etiologic factors and preventative measures. METHODS: A comprehensive Medline search (up to September 2007; subject headings: "neoplasm seeding," "laparoscopy," "urologic neoplasms") of all case reports and series related to laparoscopic urology surgery for malignant disease was performed. The references for each of these case reports and series were also reviewed for any additional reports of port-site metastases. RESULTS: Only 28 cases of port-site metastases involving urologic malignancies have been reported, with laparoscopic procedures involving upper tract transitional cell carcinoma comprising the majority (11/28 or 39%) of these. Recent reports involving renal cell carcinoma, prostatic carcinoma, and bladder cancer have been published as well. SUMMARY: The incidence of port-site metastases is comparable with that seen following open surgery. The etiology is likely multifactorial, but adhering to proper surgical technique is the most effective preventative strategy.

Urinary and sexual quality of life 1 year following robotic assisted laparoscopic radical prostatectomy.

PURPOSE: We evaluated urinary and sexual quality of life 1 year following robotic laparoscopic radical prostatectomy and identified preoperative variables predictive of a severe decrease from baseline. MATERIALS AND METHODS: Using a prospective robotic laparoscopic radical prostatectomy database we identified patients with greater than 1 year of postoperative followup. The UCLA-PCI SF-36v2 questionnaire was used to evaluate urinary and sexual quality of life before and 1 year after surgery. Severe worsening of the postoperative score was defined as a greater than 1 SD decrease. Demographic and preoperative clinical variables were evaluated along with baseline scores on univariate and multivariate analysis. RESULTS: Between February 2003 and September 2007 a total of 1,225 robotic laparoscopic radical prostatectomies were performed at our center and 361 patients (52%) met inclusion criteria. On multivariate analysis baseline urinary function was the only predictor of significant worsening of urinary function (OR 1.04, p = 0.003). Baseline urinary bother was the only predictor of significant worsening of urinary bother (OR 1.05, p <0.0001). A significant decrease in sexual function was predicted by baseline sexual function (OR 1.03, p = 0.0001), baseline sexual bother (OR 1.03, p = 0.005) and nerve sparing technique (OR 0.31, p = 0.05). Predictors of a significant decrease in sexual bother were also baseline sexual function (OR 1.02, p = 0.0001), baseline sexual bother (OR 1.04, p = 0.0007) and nerve sparing technique (OR 0.38, p = 0.02). ORs indicated that higher baseline scores corresponded to a higher risk of postoperative score worsening. CONCLUSIONS: We found that overall better baseline sexual and urinary scores are associated with better postoperative outcomes. However, the risk of a significant decrease in urinary function, urinary bother, sexual function and sexual bother is higher in patients with better baseline scores. Nerve sparing positively affects sexual function and sexual bother.

Laparoscopic nephroureterectomy: long-term outcomes.

PURPOSE OF REVIEW: Laparoscopic nephroureterectomy is becoming increasingly common since it was first described in 1991 for upper urinary tract transitional cell carcinoma, with long-term data now emerging. The purpose of this study was to compare oncological outcomes between laparoscopic nephroureterectomy and open nephroureterectomy, investigate recurrence risks specific to laparoscopic nephroureterectomy techniques and review long-term outcomes after laparoscopic nephroureterectomy. RECENT FINDINGS: Recently published long-term outcomes support the oncologic efficacy of laparoscopic nephroureterectomy, confirming results from previous studies with short and intermediate follow-up. Rates of bladder, local and distant recurrence are comparable irrespective of the various methods of managing the distal ureter and bladder cuff currently employed. SUMMARY: As the oncologic outcomes after laparoscopic nephroureterectomy continue to mature, a laparoscopic approach for the renal portion of nephroureterectomy is widely accepted as the gold standard in the treatment of organ-confined upper urinary tract transitional cell carcinoma. The roles of laparoscopic nephroureterectomy, lymph node dissection and adjuvant chemotherapy in advanced upper urinary tract transitional cell carcinoma continue to evolve and remain to be defined.

Port site metastases.

PURPOSE OF REVIEW: The aim of this article is to provide an overview of the incidence, pathophysiology, risk factors and possible methods of reducing the risk of port site metastases following uro-oncological procedures. RECENT FINDINGS: To our knowledge, 28 cases of port site metastasis have been reported in the urologic literature. There has been an increased interest in the use of intraperitoneal instillation of various tumoricidals in order to reduce the risk of port site seeding. SUMMARY: The risk of port site metastases remains low, provided that surgeons rigorously adhere to the principles of oncological surgery.

The urological personality: is it unique?

OBJECTIVES: To develop a preliminary characterization of the urological personality. METHODS: Thirty-four urology residents (29 male) from all eleven Canadian training programs anonymously completed the Revised NEO personality inventory (NEO-PI-R(c)), a commercially available validated personality assessment tool in which participants agree or disagree with a compilation of 240 statements. A score is generated in each of five character traits according to the five factor theory of personality: extraversion (E), openness (O), conscientiousness (C), agreeableness (A) and neuroticism (N). The group mean on each scale was compared to the normative mean for the general adult population using one-sample, two-tailed t tests. RESULTS: Urology residents scored significantly higher than the general population on three of the five personality factors: extraversion (E) (p<.001), openness (O) (p<.02) and conscientiousness (C) (p<.05). There was no significant difference from norms in agreeableness (A) or neuroticism (N). CONCLUSIONS: The high scores in 'extraversion' reflect the social, warm, active and talkative nature of urology residents. As well, urology residents tend to be willing to entertain new ideas and are purposeful and determined based on their high scores on 'openness' and 'conscientiousness' respectively. Canadian urology residents possess a distinct personality in comparison to the general population. These provocative findings should be interpreted with caution. If confirmed on a wider basis, the data may be helpful in career counseling and resident selection. Future studies examining differences between the urological personality and other surgical subspecialties may further refine applications of the data.