Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study.

PURPOSE: To evaluate the efficacy and safety of udenafil 75 mg once daily in patients with erectile dysfunction following bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (BNS-RALP). MATERIALS AND METHODS: A multi-center, prospective, randomized, controlled, double-blind study was conducted. Among patients with localized prostate cancer with international index of erectile function-erectile function domain (IIEF-EF) score of 18 or higher before BNS-RALP, those who developed postoperative erectile dysfunction (IIEF-EF score 14 or less at 4 weeks after BNS-RALP) were enrolled. Enrolled patients were randomly assigned to the udenafil 75 mg daily group or the placebo group in a 2:1 ratio. Each subject was followed up at 8 weeks (V2), 20 weeks (V3), and 32 weeks (V4) to evaluate the efficacy and safety of udenafil. RESULTS: In all, 101 patients were screened, of whom 99 were enrolled. Of the 99 patients, 67 were assigned to the experimental group and 32 to the control group. Ten (14.93%) patients in the experimental group and 10 (31.25%) in the control group dropped out of the study. After 32 weeks of treatment, IIEF-EF score of 22 or higher was seen in 36.51% (23/63) of patients in the experimental group and 13.04% (3/23) patients in the control group (p=0.021). The proportion of patients with IIEF-EF improvement of 25% or more compared to the baseline was 82.54% (52/63) in the experimental group and 62.96% (17/27) in the control group (p=0.058). CONCLUSIONS: Udenafil 75 mg once daily after BNS-RALP improved the erectile function without any severe adverse effects.

Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up.

BACKGROUND: Although nerve-sparing robot-assisted radical prostatectomy (NS-RALP) is performed, a large number of patients still experience erectile dysfunction (ED) after surgery. AIM: To evaluate the efficacy and safety of tadalafil 5 mg once daily (OaD) in ED treatment over 2 years and investigate the cause of vascular ED after NS-RARP. METHODS: We retrospectively evaluated 95 men who underwent NS-RARP and had a penile rehabilitation treatment with tadalafil 5 mg OaD. They were classified into 3 groups: tadalafil 5 mg OaD for 2 years (group I), tadalafil 5 mg OaD for 1 year (group II), and no tadalafil (group III). All patients in group I underwent penile color duplex ultrasound to evaluate the cause of vascular ED. OUTCOMES: Patients were surveyed using the abridged 5-item International Index of Erectile Function (IIEF-5). RESULTS: Statistically significant improvements were observed in group I for all IIEF-5 domain scores (P = .000). There was no statistically significant difference in recovery of erectile function (EF) the 2-year follow-up between groups I and II. Sub-analysis based on NS status showed no difference in recovery of EF. However, group I showed better trends in EF improvement. Those with venogenic ED had poor responses compared with those with arteriogenic ED or unremarkable findings with tadalafil 5-mg OaD treatment (14.2% vs 55.0% vs 53.3%). The overall side effects included hot flushing in 9.5%, headache in 7.1%, and dizziness in 2.3% of patients. CLINICAL IMPLICATIONS: Long-term usage of tadalafil 5 mg OaD after RARP can be an effective option for penile rehabilitation. STRENGTHS AND LIMITATIONS: The present study is a retrospective study with a relatively small sample. CONCLUSIONS: Although the responses of patients with venogenic ED were limited compared with those with arteriogenic ED, tadalafil 5-mg OaD treatment was well tolerated and significantly improved EF up to 2 years after NS-RARP. Kim S, Sung GT. Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up. Sex Med 2018;6:108-114.

Establishment of Korean prostate cancer database by the Korean Urological Oncology Society.

Purpose: Despite the necessity, to date, no detailed database of prostate cancer, especially one that includes clinicopathological data, has been created in Korea. For that reason, the Korean Urological Oncology Society (KUOS) decided to create the Korean Prostate Cancer Database (KPCD). Materials and Methods: The KPCD program was introduced in 2010. After considering regional distribution, a total of 20 hospitals participated in the KPCD. The Database consists of 4 domains (demographic, pretreatment, treatment, and follow-up data) and 135 variables. Results: In total, 7,608 men with prostate cancer between 2000 and 2010 were registered in the KPCD. The mean age at the time of diagnosis was 67.6±7.7 years. The mean PSA at diagnosis was 74.0±366.9 ng/mL, and the proportions of patients with Gleason scores of ≤6, 7, and 8-10 were 37.0%, 26.7%, and 34.2%, respectively. At diagnosis, 62.3% of the patients had localized tumors, 14.6% had regional, 12.8% had distant, and 10.4% cases were from unknown diseases. With regards to the initial treatment modality employed, 1.3% of patients were managed with active surveillance, 62.1% underwent surgery, 4.3% underwent radiotherapy, 27.1% had androgen deprivation therapy, and 5.2% underwent unknown therapies. The 5-year cancer-specific survival rate of patients in the KPCD was 98.6% in the localized stage, 94.8% in the regional stage, 74.7% in the distant stage, and 86.9% in the unknown stage. Conclusions: The KUOS created a relatively successful database of patients with prostate cancer in Korea. The KPCD will continue to improve the availability of data regarding prostate cancer.

Effect of rectal enema on intrafraction prostate movement during image-guided radiotherapy.

INTRODUCTION: Rectal volume and movement are major factors that influence prostate location. The aim of this study was to assess the effect of a rectal enema on intrafraction prostate motion. METHODS: The data from 12 patients with localised prostate cancer were analysed. Each patient underwent image-guided radiotherapy (RT), receiving a total dose of 70 Gy in 28 fractions. Rectal enemas were administered to all of the patients before each RT fraction. The location of the prostate was determined by implanting three fiducial markers under the guidance of transrectal ultrasound. Each patient underwent preparation for IGRT twice before an RT fraction and in the middle of the fraction. The intrafraction displacement of the prostate was calculated by comparing fiducial marker locations before and in the middle of an RT fraction. RESULTS: The rectal enemas were well tolerated by patients. The mean intrafraction prostate movement in 336 RT fractions was 1.11 ± 0.77 mm (range 0.08-7.20 mm). Intrafraction motions of 1, 2 and 3 mm were observed in 56.0%, 89.0% and 97.6% of all RT fractions, respectively. The intrafraction movements on supero-inferior and anteroposterior axes were larger than on the right-to-left axes (P < 0.05). The CTV-to-PTV margin necessary to allow for movement, calculated using the van Herk formula (2.5Σ + 0.7σ), was 1.50 mm. CONCLUSIONS: A daily rectal enema before each RT fraction was tolerable and yielded little intrafraction prostate displacement. We think the use of rectal enemas is a feasible method to reduce prostate movement during RT.

The Efficacy and Safety of Tadalafil 5 mg Once Daily in the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: 1-Year Follow-up.

PURPOSE: To evaluate the efficacy and safety of tadalafil 5 mg once daily use in the treatment of erectile dysfunction (ED) after robot-assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS: The study retrospectively evaluated 92 patients who underwent RALP at Dong-A University Hospital. The patients were surveyed by use of the abridged five-item version of the International Index of Erectile Function (IIEF-5) questionnaire, which was self-administered before surgery and at 6 months and 1 year after surgery. The 92 patients were classified into the tadalafil group (n=47) and the non-tadalafil group (n=45). Each group was then classified depending on the nerve-sparing (NS) procedure used: bilateral NS or unilateral NS. RESULTS: At 6 months, the total IIEF-5 scores of the tadalafil group and the non-tadalafil group were 10.0±3.4 and 7.0±4.0, respectively. At 1 year, the total IIEF-5 score in the tadalafil group was significantly greater than that in the non-tadalafil group (13.2±5.6 vs. 7.7±4.8, p<0.0001). Statistically significant improvements (p<0.05) were observed in the tadalafil group for all 5 domains of the IIEF-5 score, whereas in the non-tadalafil group there was no significant improvement in any of the domains at 1 year. The reported side effects were flushing (8.5%, n=4), headache (4.3%, n=2), and dizziness (2.1%, n=1). CONCLUSIONS: In ED patients after NS RALP, a once-daily dose of tadalafil 5 mg was well tolerated and significantly improved EF compared with that in the non-tadalafil group.

Laparoendoscopic single-site surgery with the second-generation single port instrument delivery extended reach surgical system in a porcine model.

PURPOSE: To describe our initial experience with the second-generation Single Port Instrument Delivery Extended Reach (SPIDER) laparoendoscopic single-site surgical system in a porcine model. MATERIALS AND METHODS: In four swine weighing approximately 32 to 35 kg, five nephrectomies, four adrenalectomies, three pyeloplasties, and three partial cystectomies and closures were performed by a single surgeon. The swine were placed in the lateral flank position under general anesthesia. The SPIDER surgical system was introduced through a single incision and the various urological procures were performed by use of flexible instrumentation. RESULTS: All five nephrectomies, four adrenalectomies, three pyeloplasties, and three partial cystectomies and closures were performed successfully without additional skin incisions. The mean time to set up the SPIDER platform was 3.5 minutes. The mean operative time for the right and left nephrectomies was 45.4 minutes and 47.8 minutes, respectively. The mean operative time for the right and left adrenalectomies was 37.6 minutes and 35.4 minutes, respectively. The mean operative time for the pyeloplasties for one right and two left ureters was 45.6 minutes and 47.3 minutes, respectively. The mean operative time for the partial cystectomies and closures was 18.6 minutes. There were no noticeable intraoperative complications except for minimal urine leakage in the first pyeloplasty. CONCLUSIONS: In this initial pilot evaluation, the second-generation SPIDER surgical system offered intuitive instrument maneuverability and restored triangulation. However, retraction was challenging because of the lack of strength and the limited ability for precise manipulation of the tip. Future refinements of the technology and prospective studies are needed to optimize the application of this technology in urology.

Radiofrequency ablation of renal tumors: four-year follow-up results in 47 patients.

OBJECTIVE: To retrospectively evaluate the intermediate results of radiofrequency ablation (RFA) of small renal masses (SRMs). MATERIALS AND METHODS: Percutaneous or laparoscopic RFA was performed on 48 renal tumors in 47 patients. The follow-up studies included a physical examination, chest radiography, creatinine level, and contrast-enhanced CT or MRI. To confirm the pathologic criteria of complete ablation, 35 patients underwent a follow-up biopsy. Recurrence was defined as contrast enhancement on imaging studies after 3 months, lesion growth at subsequent imaging, or viable cancer cells on follow-up biopsy. RESULTS: Technical success was achieved in 43 (89.6%) of 48 renal tumors. The mean tumor size was 2.3 cm and the mean follow-up period was 49.6 months. Repeated RFA was necessary in 5 tumors due to incomplete ablation. The overall complication rate was 35.8%, of which 96.2% were mild complications. Serum creatinine levels at 12 months after RFA did not differ from those before RFA (1.28 vs. 1.36 mg/dL). Four patients were found to have recurrence at various follow-up intervals, and distant metastasis was not found in any cases. CONCLUSION: RFA appears to be a useful treatment for selected patients with SRMs. Our 4-year follow-up results disclose an excellent therapeutic outcome with RFA, while achieving effective local tumor control.

Effect of Bladder Neck Preservation and Posterior Urethral Reconstruction during Robot-Assisted Laparoscopic Radical Prostatectomy for Urinary Continence.

PURPOSE: To report our results on urinary continence after bladder neck preservation (BNP) and posterior urethral reconstruction (PUR) during robot-assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS: Data from 107 patients who underwent RALP were compared on the basis of whether the patients underwent BNP and PUR, BNP only, or the standard technique (ST). In group A (n=31 patients), ST was performed by using Ven velthoven continuous suturing for urethrovesical anastomosis. In group B (n=28 patients), ST with only PUR was performed. In group C (n=48 patients), both the BNP and PUR techniques were used. "Recovery of continence" was defined as the use of 1 pad (50 ml) or less within 24 hours. RESULTS: The three groups were comparable in terms of patient demographics. The mean operative time and the mean blood loss decreased significantly from group A to group C (p=0.021 for mean operative time and p=0.004 for the mean blood loss). Mean catheterization time was 8.9, 7.8, and 7.1 days in each group (p=0.047). Early return of urinary continence at 3 months was observed in group B (89.2%) and group C (90.6%) compared with group A (71%). However, continence at 6 months was comparable in the 3 groups (87.5% in group A, 92.8% in group B, and 92.3% in group C). Rates of positive surgical margins decreased from 30.2% in group A to 20% in group B and 12% in group C. CONCLUSIONS: BNP and PUR during RALP showed a favorable impact on the early postoperative recovery of continence while not affecting positive surgical margins.

Radiofrequency ablation of renal tumors: our experience.

PURPOSE: To report our results of nephron-sparing radiofrequency ablation (RFA) of renal tumors. MATERIALS AND METHODS: Since August 2004, 49 patients with renal tumors were treated with either percutaneous or laparoscopic RFA. All patients underwent preoperative imaging with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) and were suspected to have renal cell carcinoma. The follow-up for each patient included a physical examination, chest radiography, liver function tests, and a contrast-enhanced CT or MRI. To confirm the pathologic criteria of complete ablation, 30 patients underwent 6-month or 1-year follow-up biopsy. Recurrence was defined as growth of the tumor or any new enhancing portions at 3 months after confirmed nonenhancement of the initial RFA lesion. RESULTS: Technical success was achieved in 46/49 cases (94%). The mean tumor size was 2.4 cm and the mean follow-up period was 31.7 months (range, 6-68 months). Of 49 patients, repeated RFA was necessary in 7 patients (14%). Three patients were found to have recurrence at various follow-up intervals. Twenty-three patients (47%) experienced complications, and all but one necessitated intervention. No distant metastasis was found in any cases, and all patients are alive and are being serially followed up. CONCLUSIONS: Percutaneous or laparoscopic RFA is considered to be a useful treatment for selected patients with small renal masses and for nephron-sparing. With a mean follow-up of 31.7 months, our intermediate data suggest excellent therapeutic outcome with RFA with effective local tumor control and preservation of renal function. The ultimate role of this modality will continue to evolve and warrants further studies.

Comparison of laparoscopic versus open radical nephrectomy for large renal tumors: a retrospective analysis of multi-center results.

OBJECTIVE: • To assess the feasibility and oncologic efficacy of laparoscopic radical nephrectomy (LRN) compared with open radical nephrectomy (ORN) in patients with large renal cell carcinomas (RCCs) > 7 cm in size. PATIENTS AND METHODS: • We analysed the data from 255 patients who underwent radical nephrectomies at 26 institutions in Korea between January 2000 and December 2007 for RCCs > 7 cm in size. • Eighty-eight patients who underwent LRNs were compared with 167 patients who underwent ORNs. The patients with tumor thrombi in the renal vein or IVC, and lymph node or distant metastases were excluded. • We compared the operative time, estimated blood loss, complication rates, and 2-year overall and disease-free survival rates between the LRN and ORN groups. RESULTS: • The median duration of postoperative follow-up was 19 months for the LRN group and 25.8 months for the ORN group. • The operative time was significantly longer in the LRN group than in the ORN group (241.5 ± 74.8 min vs 202.7 ± 69.6 min, P < 0.001) and blood loss was significantly lower in the LRN group than in the ORN group (439.8 ± 326.8 mL vs 604.4 ± 531.4 mL, P = 0.006). • No statistically significant difference was found in complication rates, the 2-year overall (92.7% vs 94%, P = 0.586) and disease-specific (90.1% vs 93.7%, P = 0.314) survival rates between the LRN and ORN groups. CONCLUSIONS: • Despite the longer operative time, LRN was an effective and less invasive treatment option for clinical T2 renal tumors. It achieved a degree of cancer control similar to that obtained with ORN.

Characteristics and prognosis of chromophobe non-metastatic renal cell carcinoma: a multicenter study.

OBJECTIVES: To analyze the characteristics and the prognostic significance of chromophobe renal cell carcinomas (chRCC). METHODS: Data about 2981 patients with non-metastatic renal cell carcinomas (RCC) at the time of surgery were retrospectively collected from 26 institutions between 1998 and 2008. All patients had undergone partial or radical nephrectomies. Of the 2981 patients, 2602 patients with conventional RCC (cRCC) and 148 with chRCC were studied. Clinical and pathological parameters were determined in all patients. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were assessed. RESULTS: Patients with chRCC differed significantly from those with cRCC on the following parameters: younger age (P=0.026), greater female ratio (P<0.001), and larger tumor diameter (P<0.001). Both groups were alike with respect to body mass index (P=0.943), Eastern Cooperative Oncology Group performance status (P=0.163), T stage (P=0.375), and Fuhrman's grade (P=0.134). The 5-year RFS rates in patients with chRCC and cRCC were 82.7% and 83.3%, respectively (P=0.762). The 5-year CSS rates in patients with chRCC and cRCC were 88.8% and 92.2%, respectively (P=0.980). Both groups showed equivalent oncological outcomes in terms of RFS and CSS for cases stratified by T stage and Fuhrman's grade. In multivariate analysis, the histological subtype was not retained as an independent prognostic variable (RFS: P=0.893; CSS: P=0.729). CONCLUSIONS: Despite being significantly different from cRCC in terms of several clinical and pathological parameters, chRCC shows equivalent oncological outcomes.

Robot-assisted radical cystectomy and pelvic lymph node dissection: a multi-institutional study from Korea.

PURPOSE: To report short-term retrospective perioperative and pathologic outcomes of the first robot-assisted radical cystectomy (RARC) series in Korea. PATIENTS AND METHODS: Between April 2007 and August 2009, 104 nonconsecutive patients, including 22 women, underwent RARC across seven institutions. We evaluated the outcomes in these cases, including operative variables, hospital recovery, pathologic outcomes, and complication rate. RESULTS: The mean age of all patients was 63.6 years (range 39-82 years), and the mean body mass index was 23.6 kg/m(2) (range 16.0-31.8 kg/m(2)). Among the 104 patients, 60 had an ileal conduit and 44 had an orthotopic neobladder. The mean total operative time was 554 minutes, and the mean blood loss was 526 mL. The time to flatus and bowel movement was about 3 days, and the time until hospital discharge was about 18 days. The mean number of lymph nodes removed were 18, and 10 patients had node metastatic disease on final pathologic evaluation. Postoperative complications occurred in 28 (26.9%) patients. CONCLUSIONS: Our initial experience with RARC appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. The current series suggests that RARC is becoming more prevalent, not only in Western countries, but also in Asian countries, just as robot-assisted radical prostatectomy has also gained widespread acceptance. Data from long-term, large, prospective, multicenter, ideally randomized comparative studies with open radical cystectomy are needed to confirm the outcome of the novel operation reported here.

Differences in tumor characteristics and prognosis in newly diagnosed Ta, T1 urothelial carcinoma of bladder according to patient age.

OBJECTIVES: To evaluate the differences in tumor characteristics and prognosis according to age at presentation in patients with newly diagnosed Stage Ta, T1 urothelial carcinoma of the bladder. METHODS: From 1998 to 2002, 1587 patients with newly diagnosed nonmuscle-invasive bladder cancer treated with transurethral resection were enrolled in this study. The median age was 63 years (range 21-98), and the median follow-up duration was 44 months (range 12-97). The study cohort was subdivided into 3 age groups: age < 60 years (group 1, n = 614), age > or = 60 but < 70 years (group 2, n = 566), and age > or = 70 years (group 3, n = 398). RESULTS: Comparing the clinical and pathologic characteristics, the tumor size (chi(2)(trend) = 4.01, P = .045), multiplicity (chi(2)(trend) = 14.50, P < .001), T category (chi(2)(trend) = 17.11, P < .001), and tumor grade (chi(2)(trend) = 31.36, P < .001) tended to increase in the older age groups. The presence of carcinoma in situ and squamous differentiation, however, did not differ among the age groups (P > .05). The 5-year recurrence-free probability was 63.6%, 52.1%, and 43.9% for groups 1, 2, and 3, respectively (P < .001). The 5-year progression-free probability was 95.7%, 91.1%, and 84.2% for groups 1, 2, and 3, respectively (P < .001). CONCLUSIONS: Stage Ta, T1 bladder urothelial carcinoma in the younger patients tended to be smaller, have fewer lesions, be less invasive, and have a more favorable tumor grade at the initial presentation. Furthermore, younger patients appeared to have a more favorable prognosis than older patients.

Radiofrequency ablation treatment for renal cell carcinoma: early clinical experience.

OBJECTIVE: To evaluate the early clinical experience associated with radiofrequency (RF) ablation in patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: The RF ablation treatment was performed on 17 tumors from 16 patients (mean age, 60.5 years; range, 43-73 years) with RCC. The treatment indications were localized, solid renal mass, comorbidities, high operation risk, and refusal to perform surgery. All tumors were treated by a percutaneous CT (n = 10), followed by an US-guided (n = 2), laparoscopy-assisted US (n = 2), and an open (n = 2) RF ablation. Furthermore, patients underwent a follow-up CT at one day, one week, one month, three and six months, and then every six months from the onset of treatment. We evaluated the technical success, technical effectiveness, ablation zone, benign periablation enhancement, irregular peripheral enhancement, and complications. RESULTS: All 17 exophytic tumors (mean size, 2.2 cm; range, 1.1-5.0 cm) were completely ablated. Technical success and effectiveness was achieved in all cases and the mean follow-up period was 23.8 months (range, 17-33 months). A local recurrence was not detected in any of the cases; however, five patients developed complications as a result of treatment, including hematuria (n = 2), mild thermal injury of the psoas muscle (n = 1), mild hydronephrosis (n = 1), and fistula formation (n = 1). CONCLUSION: The RF ablation is an alternative treatment for exophytic RCCs and represents a promising treatment for some patients with small RCCs.

Laparoscopic partial cystectomy for schwannoma of urinary bladder: case report.

Primary schwannomas of the urinary bladder are extremely rare. They arise from Schwann's cells in nerve sheaths and are often associated with von Recklinghausen's disease. In these cases, open partial cystectomy has been the choice of treatment. We performed laparoscopic partial cystectomy in a 35-year-old man who showed a 3.5-cm solid bladder mass on pelvic CT. The lesion was found to be a primary schwannoma of the urinary bladder without evidence of von Recklinghausen disease.

Laparoscopic adrenalectomy for pheochromocytoma: comparison with conventional open adrenalectomy.

PURPOSE: To compare the effectiveness and efficacy of laparoscopic transperitoneal adrenalectomy (LTA) with those of open adrenalectomy (OA) in patients with pheochromocytoma. PATIENTS AND METHODS: Among 24 patients (13 male, 11 female) who underwent surgical removal of pheochromocytoma, LTA and OA were performed in 15 and 9, respectively. The mean age was 45.2 years in the LTA group and 43.3 years in the OA group, and the mean tumor size was 5.2 +/- 2.0 (SE) cm and 6.4 +/- 2.6 cm, respectively. Retrospective analysis of their clinical outcomes was performed. The mean follow-up for OA and LTA groups was 36 months and 22 months, respectively. RESULTS: The mean operative time was 171 +/- 66.7 minutes in the LTA group and 200 +/- 73.3 minutes in the OA group. The mean blood loss was 189.5 +/- 50.4 mL and 397.1 +/- 144.7 mL, respectively (P = 0.0341). The mean number of intraoperative hypertensive crises was 0.6 +/- 0.5 during LTA and 1.67 +/- 1.1 during OA (P = 0.0146). In the LTA group, there were no conversions to open surgery and no intraoperative complications, and the blood pressure was well managed intraoperatively without medication. The mean time to oral intake was 1.1 +/- 0.3 days after LTA and 2.6 +/- 1.3 days after OA (P = 0.0037). The mean postoperative hospital stay was 5.6 +/- 2.0 days in the LTA group and 12.4 +/- 3.5 days in the OA group (P = 0.0001). Patient-controlled analgesia was needed by 2 patients (13.3%) in the LTA group and 6 (66.7%) in the OA group (P = 0.0413). In the OA group, three pneumothoraces and one case of sepsis occurred. After a mean follow-up of 36 months, two patients in the OA group redeveloped hypertension. With a mean follow-up of 22 months, none of the 15 LTA patients redeveloped hypertension. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytoma is a safe and effective prodcedure providing the benefits of a minimally invasive approach.

Laparoscopic inferior vena cava and right atrial thrombectomy utilizing deep hypothermic circulatory arrest.

BACKGROUND AND PURPOSE: Surgery for renal cancer associated with a level III or IV tumor thrombus often involves cardiopulmonary bypass, deep hypothermia, and exploration of the right atrium and inferior vena cava (IVC). This major open operation necessitates a large median sternotomy incision and a midline abdominal or chevron incision. Herein, we investigate the feasibility of purely laparoscopic IVC and right atrial thrombectomy utilizing deep hypothermic circulatory arrest. MATERIALS AND METHODS: In six male calves weighing 70 to 80 kg, the right common carotid artery and right internal jugular vein were cannulated for subsequent cardiopulmonary bypass. One laparoscopic team performed right radical nephrectomy and complete mobilization of the intra-abdominal IVC by a four-port approach. Simultaneously, a second laparoscopic team obtained three-port thoracoscopic access to incise the pericardium and expose the right atrium. In sequence, cardiopulmonary bypass, complete exsanguination, cardiac arrest, and core hypothermia of 18 degrees C were achieved. A coagulum thrombus was created by needle injection into the IVC. Combined laparoscopic and thoracoscopic incision, exploration, and thrombectomy of the IVC and the right atrium were then performed in a bloodless field. An angioscope was inserted inside the heart and the IVC to confirm complete thrombus clearance visually. The IVC and right atrium were then laparoscopically suture repaired, cardiopulmonary bypass was reestablished, and the animal was gradually rewarmed. Once sinus rhythm was reestablished at normal body temperature, the animal was weaned off the pump. RESULTS: The mean total operative time was 494.5 minutes (range 355-705 minutes). The mean time needed to lower the core temperature was 63.5 minutes (range 50-120 minutes), and the mean time required to rewarm the animal was 101.8 minutes (range 70-130 minutes). The mean blood volume drained into the pump was 2633.3 mL (range 1400-3200 mL), and the mean estimated blood loss was 350 mL (range 200-750 mL). Reestablishment of sinus cardiac rhythm and weaning off the pump was successful in all animals prior to acute euthanasia. CONCLUSIONS: Laparoscopic radical nephrectomy with thrombectomy for level III or IV tumor thrombi utilizing deep hypothermic circulatory arrest is feasible in the calf model using minimally invasive techniques exclusively. The procedure is technically complex and requires the combined efforts of expert urologic and cardiac operative teams. Survival studies are planned.

Ureteral tissue balloon expansion for laparoscopic bladder augmentation: survival study.

BACKGROUND AND PURPOSE: The search for the perfect urinary bladder substitute continues. Despite their inherent limitations, intestinal segments remain the commonest material for bladder reconstruction. The ureter, with its transitional epithelium, may be the ideal tissue to augment the bladder. Ikeguchi et al reported the feasibility of chronic ureteral balloon expansion by open surgery (J Urol 1998;159:1665). Herein, we propose a completely minimally invasive approach to balloon overdilate a segment of juxtavesical ureter incrementally and to use this in-line tissue-expanded ureteral patch to augment the bladder laparoscopically. MATERIALS AND METHODS: In five female pigs, a novel ureteral expansion balloon device (Microvasive, MA) was inserted percutaneously and advanced antegrade into the juxtavesical ureter. The device has two channels: one for balloon inflation and the other for draining the kidney. After progressive ureteral expansion over a 3- to 4-week period, laparoscopic augmentation ureterocystoplasty was performed. Animals were euthanized at 15 days (N = 1), 1 month (N = 1), 2 months (N = 1), and 3 months (N = 2). RESULTS: Percutaneous balloon device placement was technically successful in all five cases (mean operating room time 52 minutes). The mean volume of the tissue-expanded ureter at 1, 2, and 3 weeks was 12.9 cc, 60.3 cc, and 171.8 cc, respectively. Laparoscopic augmentation ureterocystoplasty with (N = 3) or without (N = 2) concomitant subtotal cystectomy was technically successful in all five cases without any open conversion. The mean operative time was 126.5 minutes, and the mean blood loss was 29 mL. Postoperative complications consisted of one case each of pyelonephritis and ureteral stricture. At autopsy, the mean capacity of the bladder was 574 mL, and the P(ves) at maximum capacity was 14 cm H(2)O. Histologic examination of the tissue-expanded ureter revealed regenerated transitional epithelium and muscle hypertrophy. CONCLUSIONS: Chronic ureteral tissue expansion can be carried out safely and efficaciously. The expanded tissue is thick, healthy, and vascular, with histologic features of normal transitional epithelium and muscle hypertrophy and hyperplasia. This expanded ureteral tissue can be used to augment the bladder with laparoscopic techniques. Such augmented bladders do not show significant shrinkage and possess urodynamic characteristic of normal capacity and normal compliance over a follow-up of 3 months.

Effect of intentional cryo-injury to the renal collecting system.

PURPOSE: We determined the short-term and long-term sequelae of intentional cryoablation of the renal pelvicaliceal system and evaluated whether continuous irrigation of the renal pelvicaliceal system with warm saline protects it against cryo-injury. MATERIALS AND METHODS: In 12 swine open bilateral renal cryoablation using an argon gas based system was performed to create a cryolesion in the lower pole that was intentionally extended into the collecting system. A single cryoprobe was used to create a 3 cm ice ball in group 1 (6 animals) and 2, 3 mm cryoprobes were used to create a 4.5 cm ice ball in group 2 (6). In all 12 right kidneys pelvicaliceal warming (range 38C to 42C) was performed using continuous retrograde saline irrigation through an indwelling 5Fr ureteral catheter. In all 12 left kidneys cryoablation was performed without pelvicaliceal warming. Real-time confirmation of caliceal involvement by the cryolesion was obtained by retrograde ureteropyelogram. Immediately after cryo-injury 6 left and 6 right kidneys were harvested for histology and the animals with a solitary kidney were followed for 1 to 3 months. RESULTS: Nadir cryoprobe tip temperature was -136C with a mean cryolesion time of 10.5 minutes. Cryolesion size was comparable in the right vs left kidneys in groups 1 and 2 (2.9 vs 3.0 and 4.7 vs 4.6 cm, respectively). Similarly cryoablation time was comparable between the right and left kidneys in groups 1 and 2 (11.3 vs 10.8 and 11.9 vs 12.2 minutes, respectively). Two animals died of aspiration pneumonia (1) and wound dehiscence (1). In all 10 surviving animals no instance of urinary extravasation was noted. At 1-month followup regrowth of normal urothelium occurred with some scarring of the lamina propria or underlying smooth muscle. Adjacent renal parenchyma was replaced by fibrous scar. At 3 months the cryo-injured collecting system was completely healed with a fibrous scar. There were no appreciable histological differences between the kidneys with or without warm pelvicaliceal irrigation. CONCLUSIONS: Our data suggest that absent physical puncture injury of the collecting system with the cryoprobe tip the cryodamaged renal collecting system heals by secondary intention in a watertight manner. These data have clinical relevance for facilitating cryoablation of a small, localized, central renal tumor in proximity to the pelvicaliceal system.

Laparoscopic ureterocalicostomy: a feasibility study.

PURPOSE: Ureterocalicostomy is occasionally indicated for reconstruction of recurrent, recalcitrant ureteropelvic junction obstruction associated with postoperative fibrosis and a relatively inaccessible renal pelvis. We investigated the feasibility of performing laparoscopic ureterocalicostomy in a survival porcine model. Anatomical, histological and chronic functional outcomes were evaluated. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 10 survival female swine. A ureteropelvic junction obstruction model was created by laparoscopic ligation of a 2 to 3 cm. segment of upper ureter. After an interval of complete ureteropelvic junction obstruction laparoscopic ureterocalicostomy was performed in a manner duplicating the steps of conventional open surgery. After transverse amputation of the lower renal pole end-to-end anastomosis of the proximal ureter to the inferior calix was formed by laparoscopic freehand suturing and knot-tying techniques. RESULTS: Mean ureter stricture length was 2.2 cm. (range 1.7 to 3.1). Mean duration of obstruction before laparoscopic ureterocalicostomy was 6.3 days (range 2 to 18). Mean operative time for laparoscopic ureterocalicostomy was 165.3 minutes (range 105 to 240). Mean estimated blood loss was 145 cc (range 25 to 400). Mean stent duration in 6 pigs was 8.7 days (range 7 to 11). Excretory urograms demonstrated immediate function with symmetrical and unobstructed drainage in all operated renal units. At 4 to 8 weeks of followup no urine leaks were noted and histological examination documented complete urothelial healing without fibrosis or scar formation. CONCLUSIONS: Laparoscopic ureterocalicostomy is technically feasible in the porcine model and it effectively duplicates the established principles of open surgery. Our technique further extends the application of laparoscopic surgery for difficult ureteropelvic junction obstruction.