Robotic simple prostatectomy.

PURPOSE: Minimally invasive approaches for large, symptomatic benign prostatic hyperplasia are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. We describe our initial experience with robotic simple prostatectomy. MATERIALS AND METHODS: Since January 2007, robotic simple prostatectomy was performed via a transperitoneal approach in 7 patients with symptomatic significant prostatomegaly on transrectal ultrasound (mean 77.66 gm). Demographic, perioperative and outcome data were recorded and all procedures were performed by the same surgeon. RESULTS: Average patient age was 63.2 years (range 56 to 72) and estimated blood loss was 298 ml (range 60 to 800). Average operative time was 205 minutes (range 120 to 300). Average hospital stay was 1.4 days (range 1 to 2), average Foley catheter duration was 7 days (range 6 to 9) and drains were removed after an average of 3.75 days (range 3 to 4). Mean specimen weight on pathological examination was 50.48 gm (range 40 to 64.5). Transfusion was necessary in 1 patient. No complications were documented. Considerable improvement from baseline was noted in International Prostate Symptom Score (preoperative vs postoperative 22 vs 7.25) and maximum urine flow (preoperative vs postoperative 17.75 vs 55.5 ml per minute). Four patients were in acute urinary retention preoperatively. CONCLUSIONS: Robotic simple prostatectomy is a feasible, reproducible procedure. Further publications are expected with larger series and larger prostatic adenomas.

Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique.

PURPOSE: To evaluate the impact of maximal urethral length preservation (MULP) technique in comparison with posterior urethral reconstruction and anterior bladder suspension (PRAS) technique on the continence rates (CR), time to achieve continence among patients with prostate cancer (PCa) undergoing robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: We prospectively analyzed the CR, time to achieve continence, pre- and postoperative prostate-specific antigen (PSA) levels, rates of positive margins among three groups of continent men with PCa undergoing RALP from whom consent was obtained. Each group consisted of 30 patients: PRAS was performed in group A, combined MULP and PRAS in group B, and MULP in group C. Continence was measured by patient self-reporting of the number of pads/24 h. RESULTS: No differences were detected in the age, preoperative PSA levels, biochemical recurrence, prostate volume, and positive margins for the three groups. Men in groups B and C had marked improvement in CR 1, 3, and 6 months after catheter removal vs group A (50% and 70% vs 10%, 90% and 96.66% vs 23.3% and 100%, 100% vs 53.3%, respectively, P<0.0001). The average and median times to continence were significantly shorter in group B (5.4 and 4 weeks) and C (3.8 and 3 weeks) vs group A (27.4 and 22.5 weeks), P<0.00001. Using Cox regression analysis, only MULP and MULP+PRAS techniques were significantly correlated with continence outcomes 1, 3, and 6 months after catheter removal. CONCLUSIONS: MULP rather than PRAS confers higher postoperative CR and shorter time to achieve continence among patients with PCa who underwent RALP without increasing risk of positive margin.

Single-site robotic cholecystectomy: efficiency and cost analysis.

BACKGROUND: Single-incision surgery has gained in popularity, and the recent development of specialized robotic and laparoscopic instruments may remove some of the ergonomic and technical difficulties associated with this approach. However, questions of cost and efficiency remain. METHODS: We prospectively collected perioperative outcome and efficiency (operative time, case volume) data for our single-site robotic cholecystectomy cases and retrospectively reviewed data for our single-incision laparoscopic cholecystectomy cases. RESULTS: There were no differences in patient characteristics or perioperative outcomes between the robotic (n = 20) and laparoscopic (n = 10) groups; operative times were equivalent (84.6 vs 85.5 min; p = 0.8737) and blood loss and complications were minimal. There was a higher robotic case volume, with an average of two robotic cases (range 1-4)/day vs one/day for laparoscopic cases (range 1-1; p = 0.0306). Streamlined instrument costs were essentially equivalent. CONCLUSIONS: Robotic single-site cholecystectomy is a safe, cost-effective alternative to single-incision laparoscopic cholecystectomy in a robot-existing model.

The microRNA miR-34a inhibits prostate cancer stem cells and metastasis by directly repressing CD44.

Cancer stem cells (CSCs), or tumor-initiating cells, are involved in tumor progression and metastasis. MicroRNAs (miRNAs) regulate both normal stem cells and CSCs, and dysregulation of miRNAs has been implicated in tumorigenesis. CSCs in many tumors--including cancers of the breast, pancreas, head and neck, colon, small intestine, liver, stomach, bladder and ovary--have been identified using the adhesion molecule CD44, either individually or in combination with other marker(s). Prostate CSCs with enhanced clonogenic and tumor-initiating and metastatic capacities are enriched in the CD44(+) cell population, but whether miRNAs regulate CD44(+) prostate cancer cells and prostate cancer metastasis remains unclear. Here we show, through expression analysis, that miR-34a, a p53 target, was underexpressed in CD44(+) prostate cancer cells purified from xenograft and primary tumors. Enforced expression of miR-34a in bulk or purified CD44(+) prostate cancer cells inhibited clonogenic expansion, tumor regeneration, and metastasis. In contrast, expression of miR-34a antagomirs in CD44(-) prostate cancer cells promoted tumor development and metastasis. Systemically delivered miR-34a inhibited prostate cancer metastasis and extended survival of tumor-bearing mice. We identified and validated CD44 as a direct and functional target of miR-34a and found that CD44 knockdown phenocopied miR-34a overexpression in inhibiting prostate cancer regeneration and metastasis. Our study shows that miR-34a is a key negative regulator of CD44(+) prostate cancer cells and establishes a strong rationale for developing miR-34a as a novel therapeutic agent against prostate CSCs.

The advanced learning curve in robotic prostatectomy: a multi-institutional survey.

Several studies have attempted to define the learning curve associated with robot-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills by novice robotic surgeons. It is unclear, however, if basic proficiency can be equated with satisfactory patient outcomes. We surveyed experienced robotic surgeons with high surgical volume in an attempt to define an "advanced" learning curve, relating to proficiency and outcomes with the robotic procedure. A questionnaire was designed to evaluate the learning curve of the RALP from basic to advanced techniques. High-volume, experienced surgeons were asked to complete this questionnaire on the basis of their personal experience with the RALP procedure. Nine institutions participated in the study accounting for a total case volume of 6,276. Median surgeon experience was 460 cases (range 325-1,500); median total operative and robotic time were 165 and 105 min, respectively. Median time to "basic proficiency" with the robot was 40 cases; proficiency in more challenging cases was approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency, and surgical margins after a median of 100, 200, and 300 procedures, respectively. These data confirm previous studies that basic proficiency with the robotic system occurs relatively quickly, after 25-40 cases. Obtaining "satisfactory outcomes" took substantially longer, from 100 to 300 cases. Satisfactory outcomes regarding surgical margins and potency took longer to obtain than continence, likely reflecting the relative complexity of cancer control and nerve-sparing compared with the vesico-urethral anastomosis.

Robotic equipment malfunction during robotic prostatectomy: a multi-institutional study.

PURPOSE: Robotic-assisted laparoscopic prostatectomy (RALP) is growing in popularity as a treatment option for prostate cancer. As a new technology, little is known regarding the reliability of the da Vinci robotic system. Intraoperative robotic equipment malfunction may force the surgeon to convert the procedure to an open or pure laparoscopic procedure, or possibly even abort the procedure. We report the first large-scale, multi-institutional review of robotic equipment malfunction. MATERIALS AND METHODS: A questionnaire was designed to evaluate the rate of perioperative robotic malfunction during RALP. High-volume, experienced surgeons were asked to complete this evaluation based on the analysis of their data. Questions included the overall number of RALPs performed, the number of equipment malfunctions, the number of procedures that had to be converted or aborted, and the part of the robotic system that malfunctioned. RESULTS: Eleven institutions participated in the study with a median surgeon volume of 700 cases, accounting for a total case volume of 8240. Critical failure occurred in 34 cases (0.4%) leading to the cancellation of 24 cases prior to the procedure, and the conversion to two laparoscopic and eight open procedures. The most common components of the robot to malfunction were the arms and optical system. CONCLUSIONS: Critical robotic equipment malfunction is extremely rare in institutions that perform high volumes of RALPs, with a nonrecoverable malfunction rate of only 0.4%.

Da Vinci prostatectomy: athermal nerve sparing and effect of the technique on erectile recovery and negative margins.

As da Vinci prostatectomy (dVP) grows in use, urologists continue to work to achieve improved sexual function while maintaining oncologic outcomes. This author set out to evaluate the impact of three different nerve-sparing techniques on not only 12-month and early erectile functional recovery but on negative margin rates as well. The author completed 400 dVP procedures, 300 of which were nerve-sparing. Series 1 utilized selective bipolar cautery for nerve sparing, series 2 used an athermal "clip and peel" posterior dissection technique, and series 3 used an athermal combined anterior and posterior dissection technique with clips and sharp dissection alone. Operative times, blood loss, and margin rates were recorded for all cases, and erectile function was measured by means of pre- and post-operative Sexual Health Inventory for Men (SHIM) score. For series 1, 2, and 3, the average total operative time was 111, 83, and 75 min, average console time was 78, 53, and 58 min, average blood loss was 125, 137, and 150 ml, respectively. Erections capable of intercourse at 3 months were seen in 14% of patients in series 1, 24% of the men in series 2, and 71% of the men in series 3. Negative margin rates were 78% for series 1, 76% for series 2, and 83% for series 3. Recovery of erectile function in the author's dVP series favors an athermal technique. Short-term data on the combined anterior/posterior approach, including the preservation of the lateral prostatic fascia in the nerve sparing, was the superior of the two athermal techniques evaluated. In addition, this combined anterior and posterior method of nerve sparing using sharp dissection and clips also resulted in the lowest positive margin rates in the author's series.

Impact of prostate size and body mass index on perioperative morbidity after laparoscopic radical prostatectomy.

PURPOSE: We prospectively evaluated the impact of body mass index (BMI) and prostate gland size on operative time, estimated blood loss (EBL) and hospital stay (LOS) in patients undergoing laparoscopic radical prostatectomy at our institution. MATERIALS AND METHODS: A total of 70 consecutive laparoscopic radical prostatectomies were performed at our institution from May 2002 to April 2003. Patients who had pelvic lymphadenectomy were excluded. A total of 62 cases were available for analysis. Two cases were converted to open surgery. Perioperative data on each group were recorded, including patient age, height, weight, American Society of Anesthesiologists score, prostate specific antigen, operative time, EBL, time to regular diet and LOS. Pathology data, including specimen weight, Gleason score and the margin status, were reviewed. Patients were grouped into 3 categories based on obesity, as measured by BMI (25 or less, 26 to 29 and greater than 29 kg/m) and prostatic gland size (less than 30, 30 to 50 g, and greater than 50 gm). Furthermore, an analysis of our initial 20, middle 20 and last 22 cases was also performed. RESULTS: Mean patient age was 63 years and mean American Society of Anesthesiologists score was 2.4. Mean operative time was 247 minutes and average EBL was 413 cc. The average LOS in all groups was 2.2 days. There were no statistically significant differences in operative parameters (operative time, EBL or LOS) among the ideal body weight (BMI 25 kg/m or less), overweight (BMI 26 to 29) and obese (BMI greater than 29) groups. The initial 20 cases, the second 20 and the last 22 had similar operative time, EBL and LOS. The surgical margin positive rate in our series was 17.7% for all stages. Of the patients 82% were completely dry at 6 months. CONCLUSIONS: In our cohort of patient body mass index (25 or less, 26 to 29 and greater than 29 kg/m) did not have a significant impact on operative or postoperative morbidity. However, a positive correlation between prostate gland size (greater than 50 gm) and EBL approached but did not achieve statistical significance. Laparoscopic prostatectomy can be performed safely in obese patients and patients with a large prostate gland.

Juvenile granulosa cell tumor of the testis.

Juvenile granulosa cell tumor of the testis is a rare type of intermediate stromal cell tumor. Only 11 cases of juvenile granulosa cell tumor of the testis have been reported to the national tumor registry as of December 2001. We report an additional case of primary juvenile granulosa cell tumor of the testis. The benign lesion was managed successfully with orchiectomy, and follow-up computed tomography revealed no evidence of recurrence at 6 months. The histopathologic features, treatment, and prognosis of this unusual tumor are reviewed.