Clinical Use of PCA3 and TMPRSS2:ERG Urinary Biomarkers in African-American Men Undergoing Prostate Biopsy.

PURPOSE: Prostate specific antigen has decreased performance characteristics for the detection of prostate cancer in African-American men. We evaluated urinary PCA3 and TMPRSS2:ERG in a racially diverse group of men. MATERIALS AND METHODS: After institutional review board approval, post-examination urine was prospectively collected before prostate biopsy. PCA3 and TMPRSS2:ERG RNA copies were quantified using transcription mediated amplification assays (Hologic, San Diego, California). Prediction models were created using standard of care variables (age, race, family history, prior biopsy, abnormal digital rectal examination) plus prostate specific antigen. Decision curve analysis was performed to compare the net benefit of PCA3 and TMPRSS2:ERG. RESULTS: Of 304 patients 182 (60%) were African-American and 139 (46%) were diagnosed with prostate cancer (69% African-American). PCA3 and TMPRSS2:ERG scores were greater in men with prostate cancer, 3 or more cores, 33.3% or more cores, greater than 50% involvement of greatest biopsy core and Epstein significant prostate cancer (p <0.01). PCA3 added to the standard of care plus prostate specific antigen model for the detection of any prostate cancer in the overall cohort (0.747 vs 0.677, p <0.0001) in African-American men only (0.711 vs 0.638, p=0.0002) and nonAfrican-American men (0.781 vs 0.732, p=0.0016). PCA3 added to the model for the prediction of high grade prostate cancer for the overall cohort (0.804 vs 0.78, p=0.0002) and African-American men only (0.759 vs 0.717, p=0.0003) but not nonAfrican-American men. Decision curve analysis demonstrated improvement with the addition of PCA3. For African-American men TMPRSS2:ERG did not improve concordance statistics for the detection of prostate cancer. CONCLUSIONS: For African-American men urinary PCA3 improves the ability to predict the presence of any and high grade prostate cancer. However, the TMPRSS2:ERG urinary assay does not add significantly to standard tools.

Neoplastic reprogramming of patient-derived adipose stem cells by prostate cancer cell-associated exosomes.

Emerging evidence suggests that mesenchymal stem cells (MSCs) are often recruited to tumor sites but their functional significance in tumor growth and disease progression remains elusive. Herein we report that prostate cancer (PC) cell microenvironment subverts PC patient adipose-derived stem cells (pASCs) to undergo neoplastic transformation. Unlike normal ASCs, the pASCs primed with PC cell conditioned media (CM) formed prostate-like neoplastic lesions in vivo and reproduced aggressive tumors in secondary recipients. The pASC tumors acquired cytogenetic aberrations and mesenchymal-to-epithelial transition and expressed epithelial, neoplastic, and vasculogenic markers reminiscent of molecular features of PC tumor xenografts. Our mechanistic studies revealed that PC cell-derived exosomes are sufficient to recapitulate formation of prostate tumorigenic mimicry generated by CM-primed pASCs in vivo. In addition to downregulation of the large tumor suppressor homolog2 and the programmed cell death protein 4, a neoplastic transformation inhibitor, the tumorigenic reprogramming of pASCs was associated with trafficking by PC cell-derived exosomes of oncogenic factors, including H-ras and K-ras transcripts, oncomiRNAs miR-125b, miR-130b, and miR-155 as well as the Ras superfamily of GTPases Rab1a, Rab1b, and Rab11a. Our findings implicate a new role for PC cell-derived exosomes in clonal expansion of tumors through neoplastic reprogramming of tumor tropic ASCs in cancer patients.

High circulating estrogens and selective expression of ERß in prostate tumors of Americans: implications for racial disparity of prostate cancer.

Although estrogen receptor beta (ERß) has been implicated in prostate cancer (PCa) progression, its potential role in health disparity of PCa remains elusive. The objective of this study was to examine serum estrogens and prostate tumor ERß expression and examine their correlation with clinical and pathological parameters in African American (AA) versus Caucasian American (CA) men. The circulating 17ß-estradiol (E2) was measured by enzyme immunoassay in blood procured from racially stratified normal subjects and PCa patients. Differential expression profile analysis of ERß was analyzed by quantitative immunohistochemistry using ethnicity-based tissue microarray encompassing 300 PCa tissue cores. In situ ERß expression was validated by quantitative reverse transcription-PCR in matched microdissected normal prostate epithelium and tumor cells and datasets extracted from independent cohorts. In comparison with normal age-matched subjects, circulating E2 levels were significantly elevated in all PCa patients. Further analysis demonstrates an increase in blood E2 levels in AA men in both normal and PCa in comparison with age- and stage-matched counterparts of CA decent. Histochemical score analysis reveals intense nuclear immunoreactivity for ERß in tumor cores of AA men than in CA men. Gene expression analysis in microdissected tumors corroborated the biracial differences in ERß expression. Gene expression analysis from independent cohort datasets revealed correlation between ERß expression and PCa progression. However, unlike in CA men, adjusted multivariate analysis showed that ERß expression correlates with age at diagnosis and low prostate-specific antigen recurrence-free survival in AA men. Taken together, our results suggest that E2-ERß axis may have potential clinical utility in PCa diagnosis and clinical outcome among AA men.

Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.

PURPOSE: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. MATERIALS AND METHODS: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. RESULTS: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. CONCLUSIONS: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

Robotic urologic reconstructive procedures.

PURPOSE OF REVIEW: This review provides an overview of reconstructive robotic procedures in urology. Recently, robotic surgeons have described techniques in urologic reconstruction. We summarize the literature regarding outcomes and surgical steps for robotic pyeloplasty, robotic ureteral neocystostomy with ureteral reimplantation and robotic ureteroureterostomy/ureterolithotomy. RECENT FINDINGS: Outcomes reveal robotic assistance has greatly decreased the morbidity of urinary tract reconstruction, when compared with open surgical techniques. In addition, the superior visual and manual acuity of the robot allows one to perform surgical steps easier as compared with conventional laparoscopy. SUMMARY: Robotic assistance provides many benefits for urinary tract reconstruction and in this review we outline the salient features, with the goal of adding these techniques to the urology armamentarium. Future outcome studies need to confirm the long-term efficacy of these techniques.

The fate of small renal masses, less then 1 cm size: outcome study.

PURPOSE: We evaluated the outcome and etiologies of small renal masses (less than 1 cm in size) discovered incidentally on 2 consecutive CTs that investigated nonurologic abdominal complaints. MATERIALS AND METHODS: A retrospective search for incidentally discovered small renal masses, less then 1 cm in size, was carried out in the files of 6 major US medical centers. 4822 such lesions had been reported over a 12 year period. A search of these patients' records revealed 1082 subsequent new CTs for non urologic complaints, allowing the assessment of the fate of the masses. Lesions enlarging, of ambivalent contour or enhancement were examined by a third multiphasic MDCT. The findings were interpreted by 2 blinded radiologists. RESULTS: Six hundred and four masses could no longer be identified, 231 were significantly smaller, 113 unchanged in size and 134 larger. Of the disappearing lesions 448 were located in the medulla, 94 both in medulla and cortex and 62 in cortex. Multiphasic MDCTs obtained in 308 masses enlarging, unchanged in size or of ambivalent appearance, revealed 7 neoplasms, 45 inflammatory lesions, 8 abscesses and 62 renal medullary necrosis. Concurrent antibiotic therapy of GI conditions may have caused some of the 496 lesions to disappear. CONCLUSION: It is questionable whether the small number of malignant neoplasms (0.4%), inflammatory lesions (5%) and renal medullary necrosis (6%) justify routine follow-up CTs and exposure to radiation. The delay in intervention in neoplastic lesions probably didn't influence tumor-free survival potential and clinical symptoms would soon have revealed inflammatory conditions. With exception of ambivalent lesions, clinical surveillance appears adequate.

Does urological cancer mortality increase with low population density of physicians?

PURPOSE: We examined the association between urological cancer mortality rates and the presence of physicians. We hypothesized that cancer mortality rates increase with a low physician population density since this would decrease the detection of cancers at an early stage. MATERIALS AND METHODS: Mortality rates for prostate cancer, bladder cancer, kidney and renal pelvis cancer, and cancer at all sites for white patients in United States counties from 2003 to 2007 were obtained from the National Vital Statistics System. High and low rate groups of counties were reviewed for each type of cancer. The high rate groups consisted of 15 or 25 counties with the highest cancer mortality rates. The low rate groups consisted of counties, selected from the same states as high rate groups, with the lowest mortality rates. Levels of physicians per 10,000 general population, income, poverty and no health insurance were compared between the high and low cancer rate groups. RESULTS: There was a statistically significant inverse association between physician population density levels and kidney and renal pelvis cancer mortality rates. The association was suggestive for bladder cancer and prostate cancer mortality but not for cancer at all sites. There was also a tendency for an inverse association between family income and cancer mortality rates. CONCLUSIONS: Kidney and renal pelvis cancer mortality rates increased significantly with a low physician population density. We found a suggestive but not significant negative association between physician population density and mortality rates for prostate cancer and bladder cancer but not for cancer at all sites. Low family income was associated with higher cancer rates.

Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVE: To evaluate the incidence of, and predictors for, lymphadenectomy in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer. PATIENTS AND METHODS: Utilizing the International Robotic Cystectomy Consortium (IRCC) database, 527 patients were identified who underwent RARC at 15 institutions from 2003 to 2009. After stratification by age group, sex, pathological T stage, nodal status, sequential case number, institutional volume and surgeon volume, logistic regression was used to correlate variables to the likelihood of undergoing lymphadenectomy (defined as ≥ 10 nodes removed). RESULTS: Of the 527 patients, 437 (82.9%) underwent lymphadenectomy. A mean of 17.8 (range 0-68) lymph nodes were examined. Tumour stage, sequential case number, institution volume and surgeon volume were significantly associated with the likelihood of undergoing lymphadenectomy. Surgeon volume was most significantly associated with lymphadenectomy on multivariate analysis. High-volume surgeons (> 20 cases) were almost three times more likely to perform lymphadenectomy than lower-volume surgeons, all other variables being constant [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.39-4.05; P = 0.002]. CONCLUSION: The rates of lymphadenectomy at RARC for advanced bladder cancer are similar to those of open cystectomy series using a large, multi-institutional cohort. There does, however, appear to be a learning curve associated with the performance of lymphadenectomy at RARC.

Prospective Observational Study of a Racially Diverse Group of Men on Active Surveillance for Prostate Cancer.

OBJECTIVE: To evaluate the risk upgrading of active surveillance (AS), we reviewed the outcomes of African American men (AA) after electing AS. AS is the standard of care for men with low-grade prostate cancer (PCa). AA are known to have more advanced PCa features and are more likely to die from PCa, thus subsequent disease progression for AA on AS is unclear. METHODS: A prospectively maintained AS database from the Southeast Louisiana Veterans Administration Medical Center, New Orleans, Lousiana was queried. We identified men with low- and very low-risk PCa (Gleason 3 + 3, PSA <10, ≤CT2a) who had undergone at least 2 prostate biopsies, including initial diagnostic and subsequent confirmatory prostate biopsies. Descriptive and comparative statistical analysis was performed using R version 3.5.1. RESULTS: From a total of 274 men on AS (70% AA), 158 men met inclusion criteria (104 AA [66%]). All patients underwent at least 2 biopsies, and 29% underwent 3 or more biopsies. The median follow-up was 2.7 years. At 3 years on AS protocol, 57% AA and 61% Caucasians demonstrated no evidence of upgrading or treatment. No significant difference was observed between upgrading or progression to treatment when comparing racial groups. Seven (4%) patients in this cohort died from non PCa-specific causes, but no patients demonstrated metastasis or death from PCa over the course of study. CONCLUSION: AA men with low-risk PCa can be safely followed with the same AS protocol as non-AA men. Further analysis with longer follow up is ongoing.

Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PURPOSE: Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. RESULTS: Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. CONCLUSIONS: Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy.

Transumbilical single-port laparoscopic partial nephrectomy in a pig model.

OBJECTIVE: To determine the feasibility, instrumentation, and learning curve for single-port laparoscopic partial nephrectomy (SPLPN) in a pig model. MATERIALS AND METHODS: Ten transumbilical SPLPN were performed using the R-Port (Advanced Surgical Concepts, Wicklow, Ireland) multi-instrument port, a 5-mm flexible laparoscope (Olympus Surgical, Orangeburg, NY, USA), and custom-engineered articulating needle drivers, graspers, and scissors (Cambridge Endo, Framingham, MA, USA). After general anaesthesia, the pig was placed in the flank position. After umbilical placement of the R-Port, Gerota's fascia was incised and hilar dissection performed with the newly engineered articulating instruments. Either the upper or lower pole of the kidney was scored and excised after placing a bulldog clamp on the renal pedicle. The bolsters were prepared with absorbable haemostat, placed at the site of excision, and secured with polyglactin sutures. RESULTS: A fascial incision of > or =2.5 cm should be made to allow adequate room for passing the instruments. Also, use of the 5 mm flexible laparoscope minimizes instrument crowding and allows for optimal visualization. The mean (sd, range) time for hilum dissection was 12.2 (4.3, 7-20) min, while that for total excision was 9.8 (1.7, 8-12) min. Modified suturing techniques were developed to achieve reconstruction in a small working space. Specialized instrumentation is essential for a successful SPLPN with no need for an additional port for triangulation. The mean duration of intracorporeal suturing was 27.7 min (declining from 40 to 15 min). The total ischaemia time decreased from 50 min in the first case to 27 min in the last (mean 37.4 min). The mean estimated blood loss was 81.1 (31.7, 50-150) mL. CONCLUSIONS: SPLPN is technically feasible but further refinement of instrumentation and techniques is needed to decrease the ischaemia time and optimize the procedure.

Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months.

OBJECTIVE: To assess the overall and disease-specific survival rates of patients undergoing robot-assisted radical cystectomy (RARC) compared with historical open cystectomy. PATIENTS AND METHODS: Survival, pathological and demographic data were collected on all patients undergoing RARC for bladder cancer from both Tulane University Medical Center and Mayo Clinic Arizona. Of a total of 80 RARCs we only included those with a follow-up of > or =6 months from surgery. Survival curves were compared with those from historical series of open cystectomy. RESULTS: Of the 80 patients 59 were identified as having a follow-up of > or =6 months from the date of surgery. The mean (range) follow-up was 25 (6-49) months. Overall survival rates at 12 and 36 months were 82% and 69%, respectively, and disease-specific survival rates were 82% and 72% at 12 and 36 months, respectively. These results are comparable to survival rates from open cystectomy. As expected, patients with lymph node-positive disease fared worse than those with lymph node-negative disease. Patients with extravesical lymph node-negative disease (pT3, pT4) fared worse than patients with organ-confined lymph node-negative disease. Also, patients with lymph node-positive disease fared worse than those with extravesical lymph node-negative disease, which is consistent with historical results of open cystectomy. CONCLUSIONS: RARC has a comparable survival rate to open cystectomy in the intermediate follow-up. Further study with a longer follow-up and more patients is necessary to determine any long-term survival benefits.

Natural orifice translumenal endoscopic surgery (NOTES) partial nephrectomy in a porcine model.

BACKGROUND: This study aimed to evaluate the feasibility of natural orifice translumenal endoscopic surgery (NOTES) transgastric partial nephrectomy without hilar clamping in a porcine model. METHODS: A 45-kg male pig was placed in the supine position after endotracheal general anesthesia. A therapeutic gastroscope was introduced through the esophagus, and a 2-cm gastrotomy was performed using a diathermy electrocautery needle at the junction of the fundus and the proximal body. After incision of Gerota's fascia, the left kidney's upper pole was excised using the thulium laser without hilar dissection or clamping. An endoscopic wire loop was used to entrap and extract the specimen into the stomach. The gastroscope was subsequently withdrawn with the intact specimen. After hemostasis via reinsertion of the endoscope was ensured, metal clips were applied endoscopically to close the gastrotomy. RESULTS: The total operative time for the NOTES transgastric partial nephrectomy was 240 min. Use of the therapeutic double-channel gastroscope allowed for scarless NOTES. The available 3.7- and 2.8-mm gastroscope ports were used for gastrotomy, excision, removal of the specimen, and endoscopic clip application. The procedure was performed in a nonischemic fashion with application of the thulium laser, which provided adequate hemostasis. No further interventions such as suturing of the renal capsule or use of hemostatic agents were required. The final specimen was 3 cm in size, and the estimated blood loss was 200 ml. A major drawback of the thulium laser was excessive smoke produced by vaporization of the tissue, which was minimized with the use of external irrigation. CONCLUSION: The findings show that NOTES transgastric partial nephrectomy with thulium laser is feasible. Further studies are needed to demonstrate long-term efficacy and provide additional data regarding practical applications of this novel approach and technique.

Posterior reconstruction before anastomosis improves the anastomosis time during robot-assisted radical prostatectomy.

BACKGROUND AND OBJECTIVES: Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction. METHODS: We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared. RESULTS: Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P<0.001). Biopsy Gleason score, pathological tumor stage, perineural invasion, median age at the time of surgery, PSA, prostate weight, and estimated blood loss were not significantly different between surgeons (P>0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1-216 minutes, surgeon 2-176 minutes; P=0.002) were significantly different between surgeons. CONCLUSION: Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.

Reaching Nonmember Advanced Practice Providers and Allied Health Care Professionals.

INTRODUCTION: The AUA (American Urological Association) partners with several organizations. However, past efforts to effectively collaborate with advanced practice provider associations, particularly SUNA (the Society of Urologic Nurses and Associates), have been unsuccessful. We define a path forward for the AUA to achieve the goal of mutually beneficial partnership. METHODS: We analyzed surveys commissioned by the AUA to determine the number of advanced practice providers in urology and the procedures performed. We then designed a survey to determine the prevalence and engagement of advanced practice providers in contemporary urological practice. We also contacted SUNA leadership to ascertain engagement with the AUA. RESULTS: The 2017 AUA Census included 172 advanced practice provider respondents, of whom 72 (41.9%) were physician assistants and 88 (51.2%) nurse practitioners. The most highly valued resources for advanced practice providers were discounted products and services (66.7%) and a sense of professional pride (62.9%). The overall response rate to the AUA member online survey was 10.5%. The majority (87%) of respondents reported having advanced practice providers in their practice. Discussions with SUNA and a survey proposal were hampered by prior disagreement with the AUA, revealing a historical divide between the organizations. CONCLUSIONS: The true number and scope of advanced practice providers in urology are not well-defined. Additionally, there is a lack of engagement and support from AUA members on a sectional and national level. The AUA should strongly consider incentivizing advanced practice provider membership through certification, job opportunities and board membership.

Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success.

Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.

Ureteropelvic junction obstruction secondary to crossing vessels-to transpose or not? The robotic experience.

PURPOSE: We compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel. MATERIALS AND METHODS: A total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound. RESULTS: Anterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence. CONCLUSIONS: Comparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.

In vitro comparison of a disposable flexible ureteroscope and conventional flexible ureteroscopes.

PURPOSE: We compared and evaluated the objective characteristics (deflection characteristics, field of view and flow rate) of a disposable flexible ureteroscope and 6 established, commercially available flexible ureteroscopes. MATERIAL AND METHODS: Six commonly used ureteroscopes, including Olympus URF-P3, Storz(R) 11278AU and 11274AAU, ACMI DUR-8 Elite and DUR-8, and Wolf 7331.001 (Richard Wolf Medical Instruments, Vernon Hills, Illinois), were compared with the recently introduced SemiFlex Scope disposable flexible ureteroscope. Specifications and purchase costs were acquired from each manufacturer. The disposable ureteroscope consisted of a reusable eyepiece and a semiflexible shaft with a 3.3Fr working channel. Active tip deflection was measured with and without the 3Fr basket, the 365 mum laser fiber and the 3Fr forceps. The flow rate and field of view of each scope were evaluated. RESULTS: Active tip deflection (down/up) was highest in the disposable ureteroscope at 300/265 degrees. Although deflection was decreased by inserting the different endoscopic tools in all ureteroscopes, the disposable ureteroscope had the highest loss in flexion characteristics (35.7% down and 39.3% up). The flow rate, measured at 25 ml per minute in the disposable ureteroscope, was significantly lower than that of other ureteroscopes. The disposable ureteroscope had a 72-degree field of view, comparable to the optical characteristics of the other scopes. Compared to the other 6 flexible ureteroscopes the purchase price of the disposable scope was significantly lower and no further maintenance/repair expenses were required. CONCLUSIONS: The disposable flexible ureteroscope has acceptable active tip deflection, field of view and flow rate compared to those of other flexible ureteroscopes on the market. Further evaluation of surgical outcomes will help delineate the definitive usefulness of the disposable flexible ureteroscope.