The impact of hospital volume, residency, and fellowship training on perioperative outcomes after radical prostatectomy.

OBJECTIVES: Although high-volume hospitals have been associated with improved outcomes for radical prostatectomy (RP), the association of residency or fellowship teaching institutions or both and this volume-outcome relationship remains poorly described. We examine the effect of teaching status and hospital volume on perioperative RP outcomes. METHODS AND MATERIALS: Within the Nationwide Inpatient Sample, we focused on RPs performed between 2003 and 2007. We tested the rates of prolonged length of stay beyond the median of 3 days, in-hospital mortality, and intraoperative and postoperative complications, stratified according to teaching status. Multivariable logistic regression analyses further adjusted for confounding factors. RESULTS: Overall, 47,100 eligible RPs were identified. Of these, 19,193 cases were performed at non-teaching institutions, 24,006 at residency teaching institutions, and 3,901 at fellowship teaching institutions. Relative to patients treated at non-teaching institutions, patients treated at fellowship teaching institutions were healthier and more likely to hold private insurance. In multivariable analyses, patients treated at residency (OR = 0.92, P = 0.015) and fellowship (OR = 0.82, P = 0.011) teaching institutions were less likely to experience a postoperative complication than patients treated at non-teaching institutions. Patients treated at residency (OR = 0.73, P<0.001) and fellowship (OR = 0.91, P = 0.045) teaching institutions were less likely to experience a prolonged length of stay. CONCLUSIONS: More favorable postoperative complication profile and shorter length of stay should be expected at residency and fellowship teaching institutions following RP. Moreover, postoperative complication rates were lower at fellowship teaching than at residency teaching institutions, despite adjustment for potential confounders.

Complications after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BACKGROUND: Complication reporting is highly variable and nonstandardized. Therefore, it is imperative to determine the surgical outcomes of major oncologic procedures. OBJECTIVE: To describe the complications after robot-assisted radical cystectomy (RARC) using a standardized and validated reporting methodology. DESIGN, SETTING, AND PARTICIPANTS: Using the International Robotic Cystectomy Consortium (IRCC) database, we identified 939 patients who underwent RARC, had available complication data, and had at least 90 d of follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Complications were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center (MSKCC) system and were defined and stratified by organ system. Secondary outcomes included identification of preoperative and intraoperative variables predicting complications. Logistic regression models were used to define predictors of complications and readmission. RESULTS AND LIMITATIONS: Forty-one percent (n=387) and 48% (n=448) of patients experienced a complication within 30 and 90 d of surgery, respectively. The highest grade of complication was grade 0 in 52%, grade 1-2 in 29%, and grade 3-5 in 19% patients. Gastrointestinal, infectious, and genitourinary complications were most common (27%, 23%, and 17%, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. Thirty and 90-d mortality was 1.3% and 4.2%, respectively. As a multi-institutional database, a disparity in patient selection, operating standards, postoperative management, and reporting of complications can be considered a major limitation of the study. CONCLUSIONS: Surgical morbidity after RARC is significant when reported using a standardized reporting methodology. The majority of complications are low grade. Strict reporting of complications is necessary to advocate for radical cystectomy (RC) and helps in patient counseling.

Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial.

OBJECTIVES: To evaluate long-term urinary outcomes in participants of a two-group randomized clinical trial comparing continence after robotic prostatectomy (RP) between those who had reconstruction of the rhabdosphincter and puboprostatic collar (double-layer anastomosis) with those who had not. METHODS: Consecutive patients (n = 116) undergoing RP at a single institution were randomized to either single- or double-layer urethrovesical (UV) anastomosis between August and December of 2007. Patients were contacted an average of 23.5 months postoperatively. A survey was performed by a third-party assessor blinded to the intervention, to evaluate urinary outcomes by International Prostate Symptom Score (IPSS), pad usage, and pad weight for those with persistent incontinence. RESULTS: Follow-up at 2 years was 86.5%. There was no statistically significant difference in demographic or preoperative functional variables between groups. There was no difference between groups regarding urine leakage weights, pad usage rates, long-term IPSS score, or IPSS bother score. Both patients in the cohort with incontinence and both with bladder neck contracture (requiring a single dilation) were in the single-layer UV anastomosis group (not significant), yet these patients had not experienced an anastomotic leak at one week. CONCLUSIONS: Long-term functional urinary outcomes were excellent for patients undergoing RP with either single- or double-layer UV anastomosis. IPSS scores and pad usage rates and weights were equivalent between groups. Although patients with single-layer anastomoses were more likely to have a leak at one-week cystogram and longer duration of catheter placement, this did not lead directly to bladder neck contracture or incontinence.

Androgen regulated TRPM8 expression: a potential mRNA marker for metastatic prostate cancer detection in body fluids.

Identification of sensitive and specific biomarkers for early detection and prognosis of prostate cancer is essential for timely and appropriate treatment of the disease in individual patients. We identified an RNA transcript with sequence homology to TRPM8 (melastatin-related transient receptor potential member 8) that was overexpressed in tumor vs. patient-matched non-tumor prostate tissues by RT-PCR differential display (DD). Semi-quantitative RT-PCR analysis revealed that TRPM8 levels were higher in tumor than in non-tumor tissue from 31 of 40 (>75%) patients examined. Overexpression of TRPM8 was independent of changes in androgen receptor (AR) mRNA levels in tumor tissue. However, in studies with established cell lines, TRPM8 expression was detectable only in AR-positive, but not in AR-negative cells, and it was suppressed by steroid deprivation or anti-androgen bicalutamide (Casodex) treatment, suggesting the requirement of AR activity for TRPM8 expression in prostate cancer cells. TRPM8 mRNA was also detected in body fluids of men. Most importantly, its levels were significantly higher (p<0.001, n=18) in urine and blood of patients with metastatic disease than in those of healthy men. However, there was no significant difference (p>0.05, n=10) in its levels between prostate cancer patients with localized disease and healthy men. Together, these studies demonstrate that TRPM8 expression is androgen regulated in prostate cancer cells and that, while tissue TRPM8 mRNA levels can be used for detection of prostate cancer, urine and blood TRPM8 mRNA levels may prove to be useful for distinguishing metastatic disease from clinically localized prostate cancer at the time of diagnosis.

Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial.

PURPOSE: Several case series have shown that reconstruction of the anterior or posterior periprostatic tissues facilitates early return of urinary continence after radical prostatectomy. We conducted a randomized clinical trial comparing early continence rates in patients undergoing urethrovesical anastomosis with or without periprostatic reconstruction. MATERIALS AND METHODS: A total of 116 consecutive patients undergoing computer assisted (robotic) prostatectomy performed by 1 of 2 experienced surgeons were randomized to single (without periprostatic reconstruction) or double layer (with periprostatic tissue reconstruction) urethrovesical anastomosis. Urinary loss was measured by pad weight at 1, 2, 7 and 30 days after catheter removal. Patients and data gatherers were blinded to treatment allocation. RESULTS: There were 57 patients randomized to the single and 59 to the double layer anastomosis group. All patients completed the study and followup. Using the conventional definition of urinary continence (0 to 1 pads daily) 26% and 34%, 49% and 46%, 51% and 54%, and 74% and 80% of patients undergoing single layer or double layer anastomoses were continent at 1, 2, 7 and 30 days, respectively (p >0.1). Of the patients in the 2 groups 7% and 15%, 14% and 14%, 16% and 20%, and 47% and 42% had no urinary leakage (0 gm or 0 pads daily) at these intervals, respectively (p >0.1). In each group 1 patient required prolonged catheterization because of cystographic evidence of anastomotic leakage. There were no other complications. CONCLUSIONS: Early urinary continence rates were high in patients undergoing single or double layer urethrovesical anastomosis. We found no improvement in early continence rates with reconstruction of the periprostatic tissues.

Synchronous bilateral adrenalectomy for adrenocorticotropic-dependent Cushing's syndrome.

Select patients with ACTH-dependent Cushing's syndrome, such as patients with persistent Cushing's disease after failed hypophysectomy or patients with ectopic ACTH production, may require bilateral adrenalectomy. Laparoscopic bilateral adrenalectomy has been described, offering definitive treatment with reduced morbidity compared with open techniques. We report on the performance of synchronous bilateral adrenalectomy treated using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). To our knowledge, the usage of this minimally invasive approach for this operation has yet to be reported in literature. The details of the case and a brief review of the literature are described herein.

Optimizing robotic renal surgery: the lateral camera port placement technique and current results.

PURPOSE: The successful completion of robot-assisted renal surgery requires optimal port placement in order to minimize arm collisions due to the bulky nature of the robotic system. We describe a novel technique of port placement to maximize range of motion during robotic renal surgery that has been used successfully in over 50 procedures and report on our results. METHODS: Five primary ports are placed utilizing a 30 degrees lens facing upward. The camera is in the most laterally placed port between the anterior axillary line and the midclavicular line, 3 to 4 cm below the costal margin. Two 8-mm robotic ports are placed 10 to 11 cm away from the camera port, triangulated towards the kidney. Assistant ports, if desired, are located medially and placed supra- (12 mm) and infraumbilically (5 mm). RESULTS: This technique resulted in the camera arm residing in an upward position, moving in a completely separate plane from the working robotic arms. We had no incidents of arm-camera collision in this position. We have used this port placement technique successfully in over 50 cases performed entirely robotically. We have had no need to change port location, redock the robotic system, or add additional ports during a procedure. CONCLUSION: We report on a port placement technique for robotic renal surgery that optimizes motion of the robotic arms, while eliminating external collisions. Placement of the camera port laterally and robotic ports anteromedially results in considerable flexibility of robotic arm movement.

Impact of previous inguinal hernia repair on transperitoneal robotic prostatectomy.

OBJECTIVE: Several investigators have noted that previous inguinal hernia repair with or without the use of prosthetic mesh might be a relative contraindication for open or laparoscopic radical prostatectomy due to the presence of adhesions and the difficulty of tissue dissection. We aimed to evaluate the impact of previous hernia repair on the performance and feasibility of robotic prostatectomy. MATERIALS AND METHODS: We performed a retrospective analysis of 354 patients who underwent robotic prostatectomy at our institution. The three patient groups were: 292 patients who had no prior hernia repair (group 1), 50 patients who had prior inguinal herniorrhaphy without the use of prosthetic mesh (group 2), and 12 patients who had prior inguinal herniorrhaphy with the use of prosthetic mesh. We compared operative time (surgeon console time), estimated blood loss, and operative complications (bladder, bowel, and/or vascular injuries) in the three groups. RESULTS: Patients with no prior herniorrhaphy (group 1), prior herniorrhaphy without mesh (group 2), and prior herniorrhaphy with mesh (group 3), had similar mean operating times (126.9 minutes, 129.3 minutes and 145.6 minutes, respectively) and similar mean estimated blood loss (152.5 ml, 140.6 ml, and 141.6 ml, respectively) during radical prostatectomy. However, compared to the group of patients who had no prior hernia repair, the group who had prior herniorrhaphy with the use of mesh had a significantly longer mean console operating time (145.6 versus 126.9 minutes, p = .012). CONCLUSION: Previous hernia surgery, with or without the use of prosthetic mesh, did not represent a significant barrier to the performance of transperitoneal robotic prostatectomy.