Use of high fidelity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: initial experience.

PURPOSE: Structured opportunities for learning communication, teamwork and laparoscopic principles are limited for urology residents. We evaluated and taught teamwork, communication and laparoscopic skills to urology residents in a simulated operating room. MATERIALS AND METHODS: Scenarios related to laparoscopy (insufflator failure, carbon dioxide embolism) were developed using mannequins, urology residents and nurses. These scenarios were developed based on Accreditation Council for Graduate Medical Education core competencies and performed in a simulation center. Between the pretest scenario (insufflation failure) and the posttest scenario (carbon dioxide embolism) instruction was given on teamwork, communication and laparoscopic skills. A total of 19 urology residents participated in the training that involved participation in at least 2 scenarios. Performance was evaluated using validated teamwork instruments, questionnaires and videotape analysis. RESULTS: Significant improvement was noted on validated teamwork instruments between scenarios based on resident (pretest 24, posttest 27, p = 0.01) and expert (pretest 16, posttest 25, p = 0.008) evaluation. Increased teamwork and team performance were also noted between scenarios on videotape analysis with significant improvement for adherence to best practice (p = 0.01) and maintenance of positive rapport among team members (p = 0.02). Significant improvement in the setup of the laparoscopic procedure was observed (p = 0.01). Favorable face and content validity was noted for both scenarios. CONCLUSIONS: Teamwork, intraoperative communication and laparoscopic skills of urology residents improved during the high fidelity simulation course. Face and content validity of the individual sessions was favorable. In this study high fidelity simulation was effective for assessing and teaching Accreditation Council for Graduate Medical Education core competencies related to intraoperative communication, teamwork and laparoscopic skills.

Efficacy and safety of the haemostasis achieved by Vivostat system during laparoscopic partial nephrectomy.

INTRODUCTION: Haemostasis remains the greatest challenge during laparoscopic partial nephrectomy. We describe the use of the Vivostat system helping effective haemostasis during laparoscopic partial nephrectomy (LPN). PATIENTS AND METHOD: Twenty-eight patients underwent LPN. Autologous fibrin sealant was prepared with the Vivostat system and applied to the resection bed. This system is an automated medical device for the preparation of an autologous fibrin sealant from the patient's blood. Pre and postoperative clinical parameters and laboratory values were evaluated, for acute and delayed bleeding. RESULTS: Median patient's age was 58 years (range, 25-75). All patients underwent LPN for renal tumors (mean size 2.5 cm; range 0.9-4.5 cm). Six resection were performed without vessels clamping, and 22 were realized with selective arterial Bulldog clamping. Haemostasis was achieved by a cellulose bolster (80%), by stitches (67%) and by sealant application after declamping (100%) (mean amount applied: 5.1 ml). The mean warm ischemia time was 26 minutes (range, 16-45) for 22 interventions. Mean blood loss was 128 cc (range, 20-500). Pre-operative and post-operative creatinine values (mean, 0.91 vs. 1 ng/mi) did not differ significantly; whereas mean Hb levels slightly decreases after surgery (mean, 14.7 vs. 12.5 g/dl). Mean operative time was 131 minutes (range, 60-190). All but one had negative surgical margins. One intraoperative bleeding occurred needing blood transfusion (1 unit). Postoperatively, we observed only 1 perirenal hematoma treated conservatively requiring blood transfusion. CONCLUSIONS: In this study, an effective haemostasis was achieved and maintained after kidney reperfusion. These data support the previous finding with the same system and encourage its use in LPN.

Case report: Laparoscopic removal of 10-cm retroperitoneal liposarcoma.

BACKGROUND: Liposarcomas are the second most frequent tumors in the retroperitoneal space and classically present as a large mass with minimal symptoms and a high local recurrence rate. The gold standard of treatment remains surgical excision. CASE REPORT: We describe the first successful removal of a well-differentiated retroperitoneal liposarcoma using a laparoscopic approach. An asymptomatic patient presented a large fatty mass in the retroperitoneal space on CT imaging. A transperitoneal laparoscopic approach was planned. A well-capsulated mass was exposed under Gerota's fascia that was dissected easily and removed completely without complications. Histologic examination revealed a well-differentiated liposarcoma. No recurrence was found at 12 months' followup. CONCLUSION: Resecting the mass completely remains the most important predictor of local recurrence and overall survival in liposarcoma. Thus, the success of radical surgical treatment is very important. The laparoscopic approach is technically safe and successful in maintaining oncologic principles and avoiding recurrences in retroperitoneal liposarcomas, representing a feasible alternative to open surgery.

Shift of tumor features in patients with clinically localized prostate cancer undergoing radical prostatectomy since the beginning of the PSA era.

AIM: To analyze trends of clinical and tumor characteristics over a 12-year period since the beginning of the prostate-specific antigen (PSA) era in a consecutive series of radical prostatectomies. PATIENTS AND METHODS: Between 1993 and 2004 a consecutive series of 1351 patients underwent radical prostatectomy for clinically localized prostate cancer (PC) in a single institution. Clinical and histopathological information was entered into our computer database and analyzed for changes over time. RESULTS: The annual frequency of surgical interventions increased from 43 to 160 (272%) during the observation period (r = 0.930; p < 0.01). The detection of PC based solely on pathological PSA levels rose impressively from 7% to 70% (r = 0.986; p < 0.01). The rates of organ-confined disease also increased significantly from 47% to 79% (r = 0.774; p < 0.01). Stage pT3a decreased somewhat from 28% to 18% (r = -0.389; n.s.) whereas pT3b decreased significantly from 26% to 3% (r = -0.729; p < 0.01). CONCLUSION: During the 12-year period, PC was increasingly detected on the basis of a pathological PSA level only and shifted significantly to more organ-confined stages. With a time delay, these findings are consistent with trends observed in large centers in the USA.

Serum levels of vascular endothelial growth factor (VEGF) and endostatin in renal cell carcinoma patients compared to a control group.

OBJECTIVES: Renal cell carcinoma (RCC) is a vascularised neoplasm. The importance of the angiogenic process in its growth and metastatic spreading is widely recognised. We assessed serum levels of endogenous endostatin and vascular endothelial growth factor (VEGF) in RCC patients and healthy volunteers, and evaluated the factors' prognostic role for patients' survival, distinguishing histologic subtypes with respect to correlation with tumour stage, grade, and size. METHODS: We considered 146 consecutive patients with RCC and 110 healthy volunteers. Serum samples from all subjects were analysed for endostatin and VEGF by using competitive enzyme immunoassays. RCC samples were compared with serum from the control group and with clinicopathologic factors and clinical outcome. RESULTS: Mean age was 63 years (range: 37-85 years) in RCC patients and 62 years (range: 23-88 years) in the control group. VEGF levels (median: 3.6 ng/ml+/-6.97; range: 0-48.4 ng/mL) were significantly higher in RCC patients, compared with controls (p=0.001). Endostatin levels did not differ significantly between the two groups (p=0.9) without correlation between endostatin and VEGF levels (p=0.09). No significant difference was found in the endostatin levels among the histologic subtypes (p=0.973) and VEGF (p=0.232). The median follow-up was 27 months (range: 1-57 months). CONCLUSIONS: Serum VEGF levels are elevated in RCC patients, compared with controls, and do not correlate significantly with circulating endostatin levels. No difference in preoperative serum VEGF and endostatin levels among the different histologic subtypes was found. In multivariate analysis VEGF and endostatin failed to be prognostic; only tumour stage and grade remained independent predictors of survival.

Autologous fibrin glue using the Vivostat system for hemostasis in laparoscopic partial nephrectomy.

OBJECTIVES: Haemostasis remains the greatest challenge during laparoscopic partial nephrectomy. Use of fibrin sealant currently is increasing. We describe first a technique for achieving effective haemostasis during laparoscopic partial nephrectomy using the Vivostat system. METHODS: Ten patients underwent laparoscopic partial nephrectomy. Autologous fibrin sealant was prepared with the Vivostat system and applied to the resection bed. This system is an automated medical device for the preparation of an autologous fibrin sealant, generating up to 5 ml of sealant from 120 ml of the patient's blood. The concentration of fibrin and the volume of sealant are stable; the sealant may be kept at room temperature for up to 8 hours before application without a loss of properties and effectiveness. The patients were evaluated for acute and delayed bleeding. RESULTS: Mean patient's age was 54 years (range, 31-68). Haemostasis was immediate in all cases after application of the sealant for 1 to 2 minutes to the resection site; no additional haemostatic measures were required. Mean warm ischemia time was 23 minutes (range, 20-27); mean blood loss was 90 cc (range, 20-200). Pre-operative and post-operative serum haemoglobin did not differ significantly (mean, 14.9 vs 12.6g/dl) and creatinine values (mean, 0.91 vs 0.95 ng/ml). Mean operative time was 136 minutes (range, 60-180). No postoperative bleeding or other complications occurred. CONCLUSIONS: In this study, immediate haemostasis was achieved and maintained after the kidney was reperfused. Our initial experience with the Vivostat system in laparoscopic partial nephrectomy has been encouraging.

Laparoscopic fenestration of lymphoceles after kidney transplantation with diaphanoscopic guidance.

In laparoscopic fenestration of lymphoceles after kidney transplantation, identification of the correct site of incision is sometimes difficult. We developed a new technique, using diaphanoscopy in 3 patients. After ultrasound-guided puncture and dilation, the correct incision site is identified by white light with a cystoscope inserted into the lymphocele cavity.

Selenium levels of patients with newly diagnosed prostate cancer compared with control group.

OBJECTIVES: To compare the toenail selenium level of patients with prostate cancer with that of controls. A tumor-protective effect of selenium has been discussed for many years. Published data about the influence of the selenium level in the plasma and toenails are controversial. METHODS: Our prospective study included 150 patients. Of these, 70 patients had recently diagnosed prostate cancer (cancer group) and 80 patients had no evidence of prostate cancer (negative digital rectal examination and prostate-specific antigen level within age-specific range or negative biopsies) or any other malignant disease (control group). Toenail clippings exhibit selenium levels for up to 1 year. Both groups were compared by assessing their selenium levels using inductively coupled plasma dynamic reaction cell mass spectrometry after microwave-assisted closed vessel digestion. The results of the selenium levels in both groups were statistically compared using the Wilcoxon test. Possible correlations between the selenium level and age, body mass index, smoking habits, and prostate cancer were analyzed by multiple regression analysis. RESULTS: The median age of the cancer and control group was 65 and 69 years, respectively. The median toenail selenium level in the cancer and control group was 528 ng/g (range 393 to 4274) and 502 ng/g (range 201 to 831), respectively (P value not statistically significant). Furthermore, no correlation was found between selenium level and age, body mass index, or smoking status. CONCLUSIONS: The patients in our study with newly diagnosed and not yet treated prostate cancer did not have different toenail selenium levels than controls. Body selenium levels may not influence prostate cancer incidence. A protective effect of selenium for prostate cancer seems questionable.

Prognostic impact of p63 and p53 expression in upper urinary tract transitional cell carcinoma.

OBJECTIVES: To analyze p63 and p53 immunoreactivity of upper urinary tract transitional cell carcinoma with respect to prognosis. p63 is required for the differentiation of normal urothelium and is expressed in both non-neoplastic urothelium and transitional cell carcinoma of the bladder. METHODS: A total of 53 upper urinary tract transitional cell carcinoma specimens were investigated immunohistochemically using a tissue microarray technique. p63 and p53 immunoreactivity was analyzed digitally with respect to associations with pT stage and grade and impact on disease-free survival. RESULTS: p63 expression was detected in 51 (96.2%) of 53 cases. Normal expression (greater than 90% of tumor cell nuclei) was observed in 1 (4.5%) of 22 Stage pT3 compared with 13 (41.9%) of 31 Stage pT1-T2 tumors (P = 0.003) and 4 (16%) of 25 G3 compared with 10 (35.7%) of 28 G2 tumors (P = 0.13). p53 overexpression (more than 10% of tumor cell nuclei) was found in 10 (18.9%) of 53 cases, including 2 (6.5%) of 31 Stage pT1-T2 and 8 (36.4%) of 22 Stage pT3 (P = 0.011) and 0 of 28 G2 and 10 (40%) of 25 G3 tumors (P <0.001). Metastatic disease was observed in 14 (26.4%) of 53 patients, including none of 14 with normal p63 expression compared with 14 (35.9%) of 39 with decreased (less than 90% of tumor cell nuclei) p63 expression (P = 0.02) and 5 (50%) of 10 patients with p53 overexpression compared with 9 (20.9%) of 43 patients with p53-negative tumors (P = 0.01). Multivariate analysis proved Stage pT3 was the only independent prognostic factor. CONCLUSIONS: Decreased p63 immunoreactivity and p53 overexpression were significantly associated with advanced tumor stages and poor prognosis. However, neither parameter was an independent prognostic factor in multivariate analysis.

Impact of tumor-associated symptoms on the prognosis of patients with renal cell carcinoma: a single-center experience of 683 patients.

OBJECTIVES: To evaluate the impact of cancer-associated symptoms present at the diagnosis of renal cell carcinoma (RCC) on the prognosis of patients. Increasing numbers of RCC are currently detected incidentally by routine ultrasonography. METHODS: From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients have been performed at our institution. Overall, tumor-specific, and progression-free survival were investigated using the Kaplan-Meier method. For multivariate analysis regarding tumor-specific survival, the Cox regression model, including risk ratios, was used. A receiver operating characteristics curve regarding the sensitivity and specificity for the association between tumor size and symptoms was used. RESULTS: Of the 683 patients, 417 patients were male and 266 female. The mean patient age was 62 years (range 16 to 88). Of the 683 patients, 141 (20.8%) presented with symptoms suspicious for cancer. The 5-year overall, progression-free, and cancer-specific survival rates were 82%, 79%, and 86%, respectively, for asymptomatic patients compared with 60%, 55%, and 65%, respectively, for patients with symptoms at diagnosis (P <0.0001, log-rank test). The cutoff value of 5 cm for the tumor diameter to result in symptoms was chosen on the receiver operating characteristic curve. Multivariate analysis found tumor grade (P = 0.001), tumor stage (P = 0.001), presence of symptoms (P = 0.013), and tumor diameter (P = 0.005) to be independent prognostic parameters for cancer-specific survival. CONCLUSIONS: Tumors larger than 5 cm were significantly more likely to cause symptoms compared with smaller tumors in our series. In multivariate analysis, patients presenting with symptoms suspicious for cancer at the diagnosis of RCC had a 1.8-fold greater risk of dying of cancer compared with patients without symptoms.

Detection of prostate cancer by TURP or open surgery in patients with previously negative transrectal prostate biopsies.

OBJECTIVES: To evaluate retrospectively the effectiveness of transurethral resection of the prostate (TURP) in diagnosing prostate cancer in patients with obstructive voiding symptoms and a history of negative transrectal prostate biopsy but elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). METHODS: In 1189 consecutive patients undergoing TURP or open prostatectomy between 1994 and 2000 for obstructive voiding symptoms, we identified 445 patients (37.4%) with at least one previous set of transrectal prostate biopsies because of an elevated PSA level and/or abnormal DRE findings. The probability to detect prostate cancer by TURP (n = 423; 95%) or open surgery (n = 22; 5%) was investigated overall, as well as related to patient age, PSA level, DRE findings, number of previous biopsies, time from biopsy to surgery, and weight of resected tissue. RESULTS: The mean number of preoperative negative biopsies per patient was 1.6 (range 1 to 8). The mean patient age was 69 years (range 48 to 89). The median PSA level and resection weight was 8.64 ng/mL and 32 g, respectively. Ninety-seven patients (21.8%) had abnormal DRE findings. Overall, prostate cancer was detected in 35 patients (7.9%). The cancer incidence was 5.5% (19 of 348) in patients with a normal DRE compared with 16.5% (16 of 97) in patients with an abnormal DRE (P <0.001; Fisher's exact test). The cancer rate was also related to age; other subgroups showed no statistically significant differences regarding cancer incidence. CONCLUSIONS: In patients with previously negative biopsies, the diagnostic yield of TURP is low. Therefore, TURP for diagnostic purposes only cannot be recommended. However, in patients with an abnormal DRE and obstructive symptoms, surgery should be preferred over alternative treatment options.

Does overweight impact on the prognosis of patients with renal cell carcinoma? A single center experience of 683 patients.

BACKGROUND AND OBJECTIVES: An increased incidence of renal cell carcinoma (RCC) in obese patients has been reported by several authors. We investigated the association of body mass index (BMI) with prognosis of patients with RCC. METHODS: From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients were performed at our institution. Patients' BMI at operation was evaluated, overall, tumor-specific and progression-free survival was investigated using the Kaplan-Meier method, for multivariate analysis the Cox regression model was used. RESULTS: Four hundred seventeen patients were males, 266 females. Mean age was 62 years (range 16-88). BMI was available in 609 (89.2%). 371/609 (60.9%) of patients exhibited a BMI greater than 25. After a mean follow-up of 41.5 months, 86 (12.6%) patients died from metastatic RCC, and 29 (4.3%) were alive with metastatic disease. A significant advantage regarding overall (P = 0.015) and progression-free (0.017) but not tumor-specific survival (P = 0.057) was found for patients with a BMI of more than 25 compared to normal-weight patients. In multivariate analysis, BMI showed no significant association with tumor-specific survival. CONCLUSIONS: Patients with a BMI of more than 25 had a better outcome compared to patients with normal weight in univariate analysis but not multivariate analysis.

Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma?

OBJECTIVES: To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases. METHODS: From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used. RESULTS: The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P <0.0001), erythrocyte sedimentation rate (P <0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P <0.0001) and serum cholesterol (P <0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved. CONCLUSIONS: Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.

Did the rate of incidental prostate cancer change in the era of PSA testing? A retrospective study of 1127 patients.

OBJECTIVES: To evaluate, in a retrospective study, the impact of routine prostate-specific antigen (PSA) testing on the rate of incidental prostate cancer in patients undergoing surgery for obstructive symptoms caused by presumed benign prostatic enlargement (BPE) and to investigate the indication of a routine biopsy before alternative treatment procedures for BPE. In the pre-PSA era, the diagnosis of incidental carcinoma was exclusively based on normal digital rectal examination (DRE) findings. METHODS: Since January 1993, 2422 operations (2283 transurethral resection of the prostate, 139 retropubic adenoma enucleations) for BPE were performed at our institution. The preoperative DRE findings and PSA level were evaluated, and patients with any suspicion for cancer were excluded. The pathologic reports of all patients were reviewed. A diagnosis of incidental carcinoma of the prostate required histologic evidence of cancer and negative DRE findings and a PSA level within age-specific reference ranges preoperatively. RESULTS: Of 2422 patients, 1127 (46.5%) had both negative DRE findings and an age-specific PSA level and were evaluated for our study. Overall, prostate cancer was diagnosed by surgery in 314 (13%) of 2422 patients. The rate of incidental prostate cancer in patients with both negative age-specific PSA levels and negative DRE findings was 6.4% (72 of 1127). CONCLUSIONS: In our series, the likelihood of detecting incidental prostate cancer by surgery was 6.4%. In the PSA era, the rate of incidental prostate cancer has been decreased by more than 50%. Today, the low rate of incidental carcinoma does not warrant routine histologic evaluation of the prostate if PSA testing and DRE are negative when alternative treatment modalities without tissue sampling are offered for the treatment of BPE.