The learning curve for robot-assisted radical cystectomy.

OBJECTIVE: Robot-assisted radical cystectomy has the potential to cure patients from bladder cancer while offering the benefits of minimally invasive surgery. We sought to evaluate the learning curve for this technically demanding procedure. MATERIALS AND METHODS: Robot-assisted radical cystectomy was attempted in 100 consecutive patients. An IRB-approved review of our robot-assisted radical cystectomy database was conducted. Total operative (OR) time, cystectomy time, pelvic lymph node dissection (PLND) time, estimated blood loss (EBL), margin positivity, complications, and length of hospital stay were compared among patients divided into 4 cohorts of increasing surgical experience. Scattergrams and continuous curves were plotted to develop a robotic cystectomy learning curve. RESULTS: Overall OR time decreased from 375 minutes in cohort 1 to 352 minutes in cohort 4, with less than 1% change in OR time after case 16. Time from incision to bladder extirpation decreased from 187 minutes in cohort one to 165 minutes in cohort 4. Time for PLND increased from 44 minutes in cohort 1 to 77 minutes in cohort 4. Lymph node yield increased from 14 nodes in cohort 1 to 23 nodes in cohort 4. Positive surgical margins decreased from 4 patients in cohort 1 to 0 patient in cohort 4. The complication rate had no change from 9 patients in cohort 1 to 9 patients in cohort 4. CONCLUSION: Operative results and oncologic outcomes for robot-assisted radical cystectomy constantly improve as the technique evolves.

Chromophobe renal cell carcinoma presenting as hemorrhagic shock: case report.

The majority of patients with chromophobe renal cell carcinoma (CRCC) are determined to be asymptomatic, with a small minority of patients having the classic triad of flank pain, hematuria, and abdominal mass. This case report describes a 56-year-old man first seen with hemorrhagic shock from retroperitoneal bleeding attributable to a large renal mass. An emergent exploratory laparotomy and radical nephrectomy were performed and the patient has since remained disease free at 3 year follow-up.

Hydrodissection for preservation of neurovascular bundle during robot-assisted radical prostatectomy.

INTRODUCTION: To describe a technique that may facilitate neurovascular bundle preservation during robot-assisted radical prostatectomy. MATERIALS AND METHODS: From December 2007 to January 2008, 10 patients underwent robot-assisted radical prostatectomy with bilateral nerve preservation. Hydrodissection of the neurovascular bundle was performed by injecting a 1:10000 epinephrine solution diluted in 0.9% normal saline into the lateral prostatic pedicle with an injection cannula needle (Wolf). Operative time, blood loss and margin status were assessed when this new technique was utilized. Erectile function status will be analyzed in the future. RESULTS: Ten potent patients underwent bilateral nerve-sparing robot-assisted radical prostatectomy with hydrodissection. Mean patient age was 54 years old. Mean preoperative Gleason score was 6.5 and mean pretreatment PSA was 7.0. Six patients were clinical stage T1c and four patients were T2a. The mean operative time was 182 minutes, with a range of 148 minutes to 230 minutes. Mean blood loss was 297 cc. Hemodynamic changes were not seen during hydrodissection or after hydrodissection. No intraoperative or postoperative complications developed. None of the ten patients developed delayed postoperative bleeding. Final pathologic stage was pT2 in eight patients, pT3 in one patient and pT4 in one patient. All surgical margins were negative, except in the patient with bladder neck invasion. CONCLUSIONS: We describe an athermal technique which may facilitate neurovascular bundle preservation. While intraoperative parameters were favorable with hydrodissection, long term sexual function results need to be analyzed.

Sexual dysfunction in patients with painful bladder syndrome is age related and progressive.

INTRODUCTION/OBJECTIVE: The degree of sexual dysfunction in patients with painful bladder syndrome (PBS) across their lifespan has not been previously documented. MATERIAL AND METHODS: The Female Sexual Function Index (FSFI) is a research tool to measure the degree of clinical female sexual dysfunction (FSD). This 19-item questionnaire evaluates FSD in six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. This study used the FSFI with the additional variables of age, geographical location, and current medications. The participants were not blinded to the fact that this study was examining the link between PBS and FSD. Each question in the survey was targeted to a specific variable of FSD and the answers were rated on a Lickert scale. RESULTS: When compared with controls, PBS patients self-report significant sexual dysfunction in all domains evaluated by the FSFI (p < 0.001). Age-specific results were observed in regards to the domains of arousal, lubrication, and pain (p < 0.01). CONCLUSIONS: PBS patients report significant FSD in all domains when compared to controls (p < 0.001). Significant differences in the domains of arousal, lubrication, and pain exist between respondents < 30 years old and in those > 50 years of age. The extent of sexual dysfunction is worse in the areas of pain in each age group evaluated. Pain is the most significant finding in patients with FSD and PBS.

Impact of body mass index on robot-assisted radical cystectomy.

BACKGROUND AND OBJECTIVES: Obesity is a major comorbidity in the Western world and influences outcomes of patient care. A minimally invasive approach towards radical cystectomy has been increasing in popularity. We sought to determine the influence of body mass index (BMI) on robot-assisted radical cystectomy. METHODS: Fifty-one consecutive patients underwent robot-assisted radical cystectomy for bladder cancer from October 2005 to April 2007 and were categorized into 3 groups based on their weight: normal (BMI <25), overweight (BMI=25 to 29) and obese (BMI= 30 to 39.9). Effect of BMI on intraoperative, pathologic, and postoperative outcomes was assessed by retrospective review of the robot-assisted radical cystectomy database. RESULTS: Mean BMI was 28.0, and 71% of the patients were overweight or obese. BMI did not correlate with age, sex, or American Society of Anesthesiologists (ASA) score. Overweight and obese patients had similar operative times and estimated blood loss compared with patients with normal BMI. Overweight and obese patients with bulky disease (pT3-4) had significantly higher rates of positive surgical margins (P=0.05). Complication rates were similar. CONCLUSION: Robotic-assisted radical cystectomy can be considered for patients of all body mass indices. Wider excision should be performed in patients with higher BMI.

Female urethral diverticulum containing a calculus: a case report.

Urethral diverticula with calculi have a low incidence as reported in the literature. This elderly female patient was first seen with recurrent urinary tract infections (UTIs), dysuria, and hematuria. She had two large stones, one in the bladder and one in a urethral diverticulum. Litholapaxy with a laser was effective in resolving both calculi. Subsequent urethral diverticulectomy was effective in removal of the urethral diverticulum.

Utility of an intra-operative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux.

PURPOSE: To assess the utility of intraoperative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux (VUR). METHODS: From September 2003 to June 2005, 24 children underwent injection of deflux for the treatment of VUR. A total of 38 ureters were treated. After deflux injection, our most recent 14 patients had a cystogram with simulated voiding phase to assess for the presence of VUR. All patients were scheduled for a voiding cystourethrogram (VCUG) three months postoperatively to assess for persistent reflux. The surgery was considered a success only if patients did not demonstrate reflux on their postoperative VCUG. RESULTS: Of the 24 patients undergoing deflux injection, 14 had complete resolution of their VUR. Eight patients had persistent VUR and 2 patients were lost to follow-up. A total of 38 ureters were injected. Twenty-seven ureters no longer refluxed, while 8 ureters continued to reflux and 3 ureters were lost to follow-up. Fourteen patients had an intra-operative cystogram with simulated voiding phase. The intra-operative cystogram with simulated voiding phase was negative in all patients except for one patient who demonstrated the presence of de novo contralateral VUR. There were 7 true negatives on intra-operative cystogram with a simulated voiding phase and 6 false negatives. CONCLUSIONS: Our results of endoscopic treatment of VUR compare well to the results reported by others in the literature. An intra-operative cystogram may demonstrate unsuspected contralateral reflux but does not appear to predict the success of deflux injections.

Ruptured superficial dorsal vein of the penis masquerading as a penile fracture: case report.

Acute onset of pain, swelling, and ecchymosis of the penis during sexual intercourse indicate a penile fracture until proven otherwise. However, there have been few case reports of isolated injuries to the dorsal penile artery or dorsal vein mimicking a penile fracture. Presented herein is a rare case of a patient who ruptured his superficial dorsal vein during intercourse.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in a horseshoe kidney.

With a continued movement toward minimally invasive surgical interventions, the range of applications treated with laparoscopic surgery will continue to grow. Laparoscopy is a preferred method for various reasons, including decreased postoperative pain, shorter inpatient hospital stays, and decreased convalescence. Ureteropelvic junction obstruction (UPJO) has traditionally been treated by open pyeloplasty. In patients with horseshoe kidneys, the blood supply is aberrant, which adds complexity to the procedure. We present the second reported case of a pediatric patient with a horseshoe kidney found to have UPJO who was successfully treated with transperitoneal laparoscopic pyeloplasty.

Aldosterone-secreting adrenal cortical carcinoma: a case report.

We present a case of aldosterone-secreting adrenal cortical carcinoma. The patient had an isolated elevation of aldosterone levels. This diagnosis should be suspected in patients first seen with hypertension and hypokalemia since this tumor may not always be considered in the differential diagnosis.

Isolated cerebellar metastasis in a patient with organ-confined, lymph node negative bladder cancer.

The majority of bladder cancer patients who develop brain metastasis have widely disseminated disease. Isolated cerebellar metastasis in patients with transional cell carcinoma (TCC) of the bladder is a rare event. We present the case of a patient with organ-confined bladder cancer who developed isolated cerebellar metastasis.

Overuse-related vascular injury of the hand--hypothenar hammer syndrome: a case report.

Although rare, vascular insufficiency is a well-recognized cause of hand pain, making a significant impact in the athletic and labor industry. Surgically correctable lesions are important to recognize since definitive treatment may alter the course of the disease and affect outcomes. Hypothenar hammer syndrome (HHS) results from anatomic predisposition and exposure to acute and chronic stress. Arteriography is the gold standard of diagnosis and severe symptomatic cases are treated with surgical resection and re-establishment of blood flow. We report such a case of HHS, its clinical course and management.

Management of esophageal carcinoma.

Esophageal cancer is a devastating disease and among the most lethal malignancies worldwide. Despite advances in chemotherapy and radiation techniques, tumor stage at the time of presentation is the most important predictor of patient survival. Surgical resection offers the only curative treatment currently employed and transhiatal, transthoracic and en bloc esophagectomy are all standard surgical procedures used in the treatment of this disease. The Surgical Oncology Service of the West Virginia University Hospital favors the transhiatal approach since it offers lower morbidity and mortality without compromising survival when compared with transthoracic and en bloc esophagectomies.

Emphysematous cystitis: a case report and literature review.

Emphysematous cystitis (EC), a rare form of cystitis, is often an incidental radiological finding but it can be associated with diffuse abdominal or suprapubic pain. The clinical course can vary from asymptomatic infection to fulminant sepsis. We present the case of a 79-year-old woman with diffuse abdominal pain, back pain accompanied with low-grade fevers, urinary frequency, urinary urgency, and emesis who was ultimately found to have emphysematous cystitis. A review of the etiology, pathogenesis, diagnosis and treatment options follows.

Apical margins after robot-assisted radical prostatectomy: does technique matter?

BACKGROUND AND PURPOSE: The apex is the most common site of an involved surgical margin after robot-assisted radical prostatectomy. We assessed the impact of two surgical techniques for dorsal vein control on surgical margins rates. PATIENTS AND METHODS: From August 2005 to January 2008, 480 patients underwent robot-assisted radical prostatectomy at Roswell Park Cancer Institute. The Roswell Park Cancer Institute Quality Assurance robotic prostatectomy database was reviewed to identify all patients with prostate cancer at the apex on final pathologic evaluation. The rate of positive apical margins was compared between two surgical techniques. Group 1 consisted of 145 patients who underwent apical dissection after cold incision of the dorsal venous complex (DVC) without previous suture ligation, and group 2 consisted of 158 patients who underwent suture ligation of the DVC before apical dissection. RESULTS: Of 480 patients, 303 (63%) patients had prostate cancer in the apex. Age, body mass index, prostate-specific antigen level, and clinical stage were similar in both groups. The overall apical positive margin rate was 5%. Group 1 patients had an apical positive margin rate of 2%, while group 2 patients had a positive margin rate of 8% (P = 0.02). Mean operative blood loss estimated by the attending anesthesiologist was 331 mL and 268 mL in group 1 and group 2, respectively (P = 0.044). One patient in group 1 needed blood transfusion. CONCLUSIONS: Cold incision of the DVC before suture ligation reduces the rate of apical margin involvement during robot-assisted radical prostatectomy.

Impact of stone location on success rates of endoscopic lithotripsy for nephrolithiasis.

OBJECTIVES: To determine whether stone location affects the stone-free rates of endoscopic lithotripsy for nephrolithiasis. METHODS: From January 2002 to August 2006, 245 patients with 272 stones, ranging from 4 to 20 mm in size, underwent ureteroscopy (URS) with laser lithotripsy at West Virginia University Hospital. The patients were followed up postoperatively with noncontrast spiral computed tomography, abdominal plain radiography, renal ultrasonography, or retrograde pyelography. Patients were considered to have been treated successfully if they had no residual stones. All pediatric patients were excluded, as were all patients with stones greater than 2 cm. Also, patients who had undergone previous shock wave lithotripsy, percutaneous nephrolithotripsy, or URS by an outside urologist were excluded. RESULTS: A total of 86 kidney stones were treated with URS and laser lithotripsy. Of these, 81 (94.2%) were successfully treated. Five patients (5.8%) had persistent stones. All 18 upper pole stones (100%) were cleared, 23 (95.8%) of 24 middle pole stones were cleared, and 40 (90.9%) of 44 lower pole stones were cleared (P = 0.338). CONCLUSIONS: URS is an important tool for treating nephroureterolithiasis with excellent success rates and minimal morbidity. The results of our study have shown that stone location does not significantly affect stone clearance rates when performing endoscopic lithotripsy for intrarenal calculi.

Impact of patient age on distal hypospadias repair: a surgical perspective.

OBJECTIVES: To assess whether the age at which the initial hypospadias repair is performed influences the complication rate of hypospadias repair. METHODS: The records of 325 consecutive patients who underwent initial hypospadias repair were reviewed. The patients with glanular and coronal hypospadias underwent repair with either meatoplasty and glanuloplasty or a glans approximation procedure. Patients with subcoronal hypospadias and penile hypospadias underwent repair with tubularized incised plate urethroplasty. The patients were divided into 6-month age groups, and the complication rates were analyzed by age group using the chi-square test. RESULTS: A total of 325 hypospadias repairs were performed from January 1999 to January 2005 by a single surgeon. Of the 325 cases, 194 tubularized incised plate procedures were performed, 69 meatoplasty and glanuloplasty procedures were performed, and 53 glans approximation procedures were performed. Nine tubularized island flap urethroplasties performed for penoscrotal hypospadias were excluded because we did not perform a significant number of proximal urethroplasties. Nineteen patients (6.0%) developed urethrocutaneous fistulas and six (1.9%) demonstrated dehiscence. Overall, 2 patients (2.2%) who underwent surgical repair within the first 6 months of age developed complications compared with 23 patients (10.3%) who underwent initial hypospadias repair when they were older than 6 months of age (P = 0.006). CONCLUSIONS: Tubularized incised plate, meatoplasty and glanuloplasty, and glans approximation urethroplasty are all excellent options for the surgical correction of hypospadias in the appropriately selected patient. The results of our study have indicated that complications are minimized when hypospadias repair is performed when the patient is 4 to 6 months of age.

Renal cell carcinoma and end stage renal disease.

PURPOSE: Patients with ESRD secondary to acquired renal cystic disease have been reported to have a higher incidence of RCC than the general population. We examined the clinical and pathological significance of incidental renal masses in patients with ESRD. MATERIALS AND METHODS: From January 1994 to July 2000, 852 consecutive patients with ESRD who were being considered for renal transplantation at University of Mississippi Medical Center were evaluated with renal ultrasound as part of assessment for possible kidney transplantation. Those patients with ultrasound suspicious for a malignant renal lesion were further evaluated with CT of the abdomen with and without intravenous contrast medium. Any patient with CT findings suspicious for RCC was recommended to undergo radical nephrectomy before kidney transplantation. RESULTS: A total of 19 patients had CT criteria for a possible malignant renal lesion. Seven patients had Bosniak class 3 renal cysts and 12 patients had solid, enhancing renal masses. Of the patients 17 underwent radical nephrectomy. On pathological examination 14 patients had RCC with a 1.64% prevalence in the population screened. Mean Fuhrman nuclear grade in our patients was 2.45. CONCLUSIONS: RCC in patients with ESRD are of clinical significance, considering the size, grade, histology and pathological stage of these tumors. The higher prevalence of clinically significant RCC in patients with ESRD as well as the risk of cancer progression while patients are on immunosuppressive medications justifies screening for RCC in patients with ESRD who are awaiting renal transplantation.

Laparoscopic retroperitoneal resection of blind-ending bifid ureter in patient with recurrent urinary tract infections.

Blind-ending bifid ureters are rare congenital anomalies. Symptomatic patients require surgical resection of the blind-ending ureter. Traditionally, open resection of the blind-ending segment has been performed. We describe a laparoscopic retroperitoneal three-port approach for resection of blind-ending bifid ureters. We believe this is a viable and less-invasive alternative to traditional open surgical resection of a blind-ending segment.

Primary synovial sarcoma of the kidney.

Primary renal synovial sarcomas (SS) are rare tumors of the kidney. Faria first described primary renal synovial sarcoma in 1999. Twenty-one cases of primary renal synovial sarcoma have been reported to date. Primary renal synovial sarcomas can exist in either a monophasic or a biphasic pattern. The monophasic variant of primary renal synovial sarcoma is more common and tends to have a better prognosis than the biphasic variant. We present the case of a 61 year-old woman with a monophasic variant of primary renal synovial sarcoma.