Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan.

OBJECTIVE: To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan. METHODS: Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates. RESULTS: Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series. CONCLUSIONS: Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Epidermal Growth Factor Receptor Status in Circulating Tumor Cells as a Predictive Biomarker of Sensitivity in Castration-Resistant Prostate Cancer Patients Treated with Docetaxel Chemotherapy.

OBJECTIVE: We examined whether epidermal growth factor receptor (EGFR) expression in circulating tumor cells (CTCs) can be used to predict survival in a population of bone-metastatic castration-resistant prostate cancer (mCRPC) patients treated with docetaxel chemotherapy. METHODS: All patients with mCRPC who had experienced treatment failure with androgen-deprivation therapy and had received docetaxel chemotherapy were eligible. CTCs and EGFR expression in CTCs were enumerated with the CellSearch System in whole blood. This system is a semi-automated system that detects and enriches epithelial cells from whole blood using an EpCAM antibody-based immunomagnetic capture. In addition, the EGFR-positive CTCs were assessed using CellSearch® Tumor Phenotyping Reagent EGFR. RESULTS: The median CTC count at baseline before starting trial treatment was eight CTCs per 7.5 mL of blood (range 0-184). There were 37 patients (61.7%) who had ≥5 CTCs, with median overall survival of 11.5 months compared with 20.0 months for 23 patients (38.3%) with <5 CTCs (p < 0.001). A total of 15 patients (40.5%, 15/37) with five or more CTCs were subjected to automated immunofluorescence staining and cell sorting for EGFR protein. Patients with EGFR-positive CTCs had a shorter overall survival (OS) (5.5 months) than patients with EGFR-negative CTCs (20.0 months). CTCs, EGFR-positive CTCs, and alkaline phosphatase (ALP) were independent predictors of overall survival time (p = 0.002, p < 0.001, and p = 0.017, respectively). CONCLUSION: CTCs may be an independent predictor of OS in CRPC treated with docetaxel chemotherapy. The EGFR expression detected in CTCs was important for assessing the response to chemotherapy and predicting disease outcome.

Initial operative experience of single-port retroperitoneal laparoscopic nephrectomy.

This paper reports our early experience with single-port laparoscopic nephrectomy via the retroperitoneal approach. Since April 2010, 23 patients have undergone single-port laparoscopic surgery for simple nephrectomy (n = 11 patients) and radical nephrectomy (n = 12) by an experienced laparoscopic surgeon. The mean operative time was 265.2 min and the mean estimated blood loss was 96.7 mL. The procedure was completed in all patients without conversion to standard laparoscopy or open surgery. No intraoperative or acute postoperative complications occurred. When the single-port retroperitoneal laparoscopic nephrectomy group was retrospectively compared with the group that had undergone standard retroperitoneal laparoscopic nephrectomy, no significant difference was noted with respect to age, body mass index, operation time, time to eat, catheter removal or length of hospitalization (P > 0.05). A significant difference in favor of the single-port retroperitoneal laparoscopic nephrectomy group was noted with respect to the estimated blood loss (P = 0.027) and the visual analog pain scale score at discharge (P = 0.016). Although our findings show that retroperitoneal single-port laparoscopic nephrectomy is feasible with advanced techniques and optimal instrumentation, further study is required to determine the future extent of its clinical application.

[Comparison of clinical results between TUR-P and holmium laser enucleation of the prostate (HoLEP) based on the initial experience].

OBJECTIVE: We compared the surgical results between holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TUR-P) for the treatment of men with benign prostatic hyperplasia (BPH). METHODS: A total of 87 patients with symptomatic BPH were analysed. HoLEP was performed on 46 men (mean age 68.2 +/- 7.5 years old) from December 2005 to February 2007, and TUR-P was performed on 41 men (mean age 69.2 +/- 7.3 years old) from April 2004 to March 2006. RESULTS: Both groups were comparable in terms of age, pre-operative IPSS, QOL index, urodynamic study results and prostate volume. During operation, decrease in hemoglobin was less in the HoLEP group than in the TUR-P group (1.15 +/- 1.2 vs 1.91 +/- 1.3 g/dl p < 0.05). The operation time was significantly longer in the HoLEP group than in the TUR-P group (161.9 +/- 65.0 vs. 118.3 +/- 36.9 minutes p < 0.001). Mean resected weight was 29.3 +/- 13.3 g (10-55) in the TUR-P group and 34.8 +/- 33.4 g (5-148) in the HoLEP group (p = 0.337). The catheterization period (52.1 +/- 29.6 vs. 115.2 +/- 27.5 hour p < 0.001) and hospital stay (6.6 +/- 2.3 vs. 9.4 +/- 2.2 days p < 0.001) were significantly shorter in the HoLEP group than in the TUR-P group. At follow up, Qmax, average flow rate and post void residual urine (PVR) in two groups improved significantly, and these parameters were not significantly different between the groups after 3 months. CONCLUSIONS: Both TUR-P and HoLEP were effective in relieving BOO. The estimated blood loss, a catheterization time and hospitalization were less or shorter in the HoLEP group. HoLEP may be a good alternative to the conventional transurethral electrocautery resection of the prostate for symptomatic BPH.

[Survey of factors underlying treatment choice for patients with localized prostate cancer (radical prostatectomy vs extrabeam radiotherapy)].

PURPOSE: Little is known regarding factors for decision-making on treatment by localized prostate cancer patients. We therefore conducted a survey series of cases for influence on treatment decision making, and also satisfaction after therapy. MATERIALS AND METHODS: A total of 51 patients with localized prostate cancer treated with radical prostatectomy (RP) or external beam radiation therapy (EBRT) were mailed original questionnaires about their treatment decision-making factors and satisfaction and the results compared between the two groups. RESULT: Some 48 (94.1%) patients responded to the questionnaire, 38 (79.2%) and 10 (20.8%) after RP and EBRT, respectively. The major factor determining the decision as to treatment approach was the physician in both groups (more than 90%). Excluding physicians, family or others were more important in the RP group than the EBRT group (p = 0.023). RP group patients desired removal of their prostate for cancer control, while, EBRT group patients favored the less invasive approach in consideration of side effects. Over 80% patients indicated they would definitely or probably choose the same treatment again, although some of the RP group would switch to watchful-waiting because of sexual dysfunction, urinary incontinence and the invasive nature of the procedure. CONCLUSION: Physicians are in a most important position to help patients understand prostate cancer and treatment, outcomes, and need to help them make their best choice, with appropriate follow up including mental care.

Circulating tumor cells as a biomarker predictive of sensitivity to docetaxel chemotherapy in patients with castration-resistant prostate cancer.

AIM: We examined whether Circulating Tumor Cells (CTCs) can be used to predict survival in patients with bone-metastatic castration-resistant-prostate cancer (mCRPC) treated with docetaxel chemotherapy. PATIENTS AND METHODS: All patients with mCRPC who had experienced treatment failure with androgen deprivation therapy and had received docetaxel chemotherapy were eligible for study inclusion. CTCs in whole blood were enumerated with the CellSearch System. RESULTS: The median CTC count at baseline before starting trial treatment was 7 (range=0-227) CTCs per 7.5 ml blood. Out of the 57 patients, 24 (42.1%) had a CTC count of less than 5, while 27 patients (47.4%) had a CTC count of 5-50 and six patients (10.5%) had a CTC count of more than 50. A threshold of 5 or more CTCs per 7.5 ml blood was used to assess the ability to predict survival. The patient charts were examined to determine the median overall survival time, which ranged from 6 to 37 months (mean=12.8±8.1 months, median=15.3 months). Thirty-three patients (57.9%) had 5 or more CTCs before docetaxel chemotherapy, with a median overall survival of 10.5 months compared to 25.0 months for 24 patients (42.1%) with fewer than 5 CTCs (p<0.001). CTC and alkaline phosphatase (ALP) were independent predictors of overall survival time (p=0.004, and p=0.023, respectively). In addition, poorer overall survival was predicted by a CTC count of 5 or more after three courses of docetaxel chemotherapy. CONCLUSION: The CTC count may be an independent predictor of overall survival in patients with mCRPC treated with docetaxel chemotherapy. The numbers of CTCs detected was important in assessing response to chemotherapy and predict disease outcome.

Retroperitoneal laparoscopic single-site nephroureterectomy: Initial operative experience.

INTRODUCTION: Our aim was to describe our early experience with laparoendoscopic single-site surgery (LESS) via the retroperitoneal approach for upper urinary tract tumors. METHODS: Since April 2010, 21 patients with upper urinary tract cell carcinoma were treated by our team: 12 patients have undergone LESS nephroureterectomy and 9 have undergone standard retroperitoneal laparoscopic surgery. In our LESS procedure, we employed a bendable grasper in the non-dominant hand and a standard straight laparoscopic instrument in the dominant hand. Nephrectomy was performed using procedures similar to those of conventional laparoscopic nephrectomy. In standard laparoscopic nephroureterectomy, the distal ureter and bladder cuff were excised by using the open method. RESULTS: All operations using retroperitoneal LESS nephroureterectomy were completed without conversion to standard laparoscopy or open surgery. No intraoperative or acute postoperative complications occurred. We compared the results of the retroperitoneal single-port laparoscopic surgery group to the standard retroperitoneal laparoscopic surgery group and found that the retroperitoneal LESS nephroureterectomy had significantly less estimated blood loss (P = 0.034). No significant difference was noted with respect to age, BMI, operation time, time to oral intake, length of hospitalization, and the visual analog pain scale score at discharge ( P > 0.05). CONCLUSION: The initial reports of retroperitoneal LESS nephroureterectomy demonstrate that the technique is a safe and feasible procedure for upper urinary tract urothelial carcinoma.

Two von Recklinghausen's disease cases with pheochromocytomas and gastrointestinal stromal tumors (GIST) in combination.

We here document two cases of von Recklinghausen's disease with both pheochromocytomas and gastrointestinal stromal tumors (GIST). It is very rare that these three disorders are found to occur simultaneously, although the fact that preoperative detection of GIST is difficult except with large tumors may be important in this respect. In the present cases, GIST were not evident on preoperative computed tomography and magnetic resonance imaging, and were identified unexpectedly during surgery. Our findings indicate that investigation of the intraperitoneal space should be performed during adrenalectomy for pheochromocytomas with von Recklinghausen's disease.