Setting up a pediatric robotic urology program: A USA institution experience.

Implementing a robotic urological surgery program requires institutional support, and necessitates a comprehensive, detail-oriented plan that accounts for training, oversight, cost and case volume. Given the prevalence of robotic surgery in adult urology, in many instances it might be feasible to implement a pediatric robotic urology program within the greater context of adult urology. This involves, from an institutional standpoint, proportional distribution of equipment cost and operating room time. However, the pediatric urology team primarily determines goals for volume expansion, operative case selection, resident training and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present. This review specifically highlights these factors in relationship to establishing and maintaining a pediatric robotic urology program. In addition, we share our data involving robot use over the program's first nine years (December 2007-December 2016).

The impact of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy.

PURPOSE: To examine the effect of days off between cases on perioperative outcomes for robotic-assisted laparoscopic prostatectomy (RALP). METHODS: We analyzed a single-surgeon series of 2036 RALP cases between 2003 and 2014. Days between cases (DBC) was calculated as the number of days elapsed since the surgeon's previous RALP with the second start cases assigned 0 DBC. Surgeon experience was assessed by dividing sequential case experience into cases 0-99, cases 100-249, cases 250-999, and cases 1000+ based on previously reported learning curve data for RALP. Outcomes included estimated blood loss (EBL), operative time (OT), and positive surgical margins (PSMs). Multiple linear regression was used to assess the impact of the DBC and surgeon experience on EBL, OT, and PSM, while controlling for patient characteristics, surgical technique, and pathologic variables. RESULTS: Overall median DBC was 1 day (0-3) and declined with increasing surgeon case experience. Multiple linear regression demonstrated that each additional DBC was independently associated with increased EBL [ß = 3.7, 95% CI (1.3-6.2), p < 0.01] and OT [ß = 2.3 (1.4-3.2), p < 0.01], but was not associated with rate of PSM [ß = 0.004 (-0.003-0.010), p = 0.2]. Increased experience was also associated with reductions in EBL and OT (p < 0.01). Surgeon experience of 1000+ cases was associated with a 10% reduction in PSM rate (p = 0.03) compared to cases 0-99. CONCLUSIONS: In a large single-surgeon RALP series, DBC was associated with increased blood loss and operative time, but not associated with positive surgical margins, when controlling for surgeon experience.

Robotic-assisted pelvic lymph node dissection for prostate cancer: frequency of nodal metastases and oncological outcomes.

PURPOSE: Limited data are available regarding the oncologic efficacy of pelvic lymph node dissection (PLND) performed during robotic-assisted laparoscopic prostatectomy (RALP) for prostate cancer. We aimed to determine the frequency of pelvic lymph node metastasis and oncological outcomes following RALP with PLND in patients who did not receive adjuvant androgen deprivation therapy (ADT). METHODS: We retrospectively reviewed the records of 1740 consecutive patients who underwent RALP and extended PLND. The primary endpoint was biochemical recurrence (BCR). The estimated BCR probability was obtained using the Kaplan-Meier method. Cox proportional hazard regression models were used to assess for predictors of BCR. RESULTS: One hundred and eight patients (6 %) with positive LNs were identified. The median number of LNs removed was 17 (IQR 11-24), and median follow-up was 26 months (IQR 14-43). Ninety-one (84 %) patients did not receive adjuvant ADT of whom 60 % had BCR with a median time to recurrence of 8 months. The 1- and 3-year BCR-free probability was 42 and 28 %, respectively. Patients with ≤2 LN+ had significantly better biochemical-free estimated probability compared to those with >2 LN+ (p = 0.002). The total number of LN+ (HR = 1.1; 95 % CI 1.01-1.2, p = 0.04) and Gleason 8-10 (HR = 1.96; 95 % CI 1.1-3.4, p = 0.02) were predictors of BCR on multivariate analysis. CONCLUSION: Among men with positive lymph nodes at time of robotic prostatectomy, those with two or fewer positive nodes and Gleason <8 exhibited favorable biochemical-free survival without adjuvant therapy.

Bloody otorrhea after robotically assisted laparoscopic prostatectomy.

Bilateral bloody otorrhea is a rare complication of surgery and to our knowledge a previously unpublished event. We review the case of a 50-year-old male who underwent robotic-assisted laparoscopic radical prostatectomy (RALP) with bilateral lymphadenectomy for Gleason's Score 4 + 4 = 8 prostate cancer. Bloody discharge from bilateral auditory canals was noted upon removal of the surgical drapes. Otolaryngologic examination revealed bilateral anterior auditory canal hematomas without any loss of hearing. Steep Trendelenburg position in combination with perioperative anticoagulants may have contributed to this complication. Given the rarity of this event no specific risk factors are identified.

Early removal of urethral catheter with suprapubic tube drainage versus urethral catheter drainage alone after robot-assisted laparoscopic radical prostatectomy.

PURPOSE: Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. MATERIALS AND METHODS: Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. RESULTS: A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. CONCLUSIONS: Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.

Short (≤ 1 mm) positive surgical margin and risk of biochemical recurrence after radical prostatectomy.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: It has been suggested that a very short positive margin does not confer additional risk of BCR after radical prostatectomy. This study shows that even very short PSM is associated with increased risk of BCR. OBJECTIVE: To re-evaluate, in a larger cohort with longer follow-up, our previously reported finding that a positive surgical margin (PSM) ≤ 1 mm may not confer an additional risk for biochemical recurrence (BCR) compared with a negative surgical margin (NSM). PATIENTS AND METHODS: Margin status and length were evaluated in 2866 men treated with radical prostatectomy (RP) for clinically localized prostate cancer at our institution from 1994 to 2009. We compared the BCR-free survival probability of men with NSMs, a PSM ≤ 1 mm, and a PSM < 1 mm using the Kaplan-Meier method and a Cox regression model adjusted for preoperative prostate-specific antigen (PSA) level, age, pathological stage and pathological Gleason score (GS). RESULTS: Compared with a NSM, a PSM ≤ 1 mm was associated with 17% lower 3-year BCR-free survival for men with pT3 and GS ≥ 7 tumours and a 6% lower 3-year BCR-free survival for men with pT2 and GS ≤ 6 tumours (log-rank P < 0.001 for all). In the multivariate model, a PSM ≤ 1 mm was associated with a probability of BCR twice as high as that for a NSM (hazard ratio [HR] 2.2), as were a higher PSA level (HR 1.04), higher pathological stage (HR 2.7) and higher pathological GS (HR 3.7 [all P < 0.001]). CONCLUSION: In men with non-organ-confined or high grade prostate cancer, a PSM ≤ 1 mm has a significant adverse impact on BCR rates.

How accurate is our clinical prediction of "minimal prostate cancer"?

BACKGROUND: Recommendations for active surveillance versus immediate treatment for low risk prostate cancer are based on biopsy and clinical data, assuming that a low volume of well-differentiated carcinoma will be associated with a low progression risk. However, the accuracy of clinical prediction of minimal prostate cancer (MPC) is unclear. OBJECTIVES: To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction. METHODS: Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as < 5% of prostate volume involvement with organ-confined Gleason score < or = 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction. RESULTS: MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason's score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. Conversely, when applying the most favorable preoperative conditions (Gleason < or = 6, < 20% positive cores, MCL < or = 11.5%) the chance of minimal disease was 41%. CONCLUSIONS: Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance.

A Contemporary Report of Low-Dose-Rate Brachytherapy for Prostate Cancer Using MRI for Risk Stratification: Disease Outcomes and Patient-Reported Quality of Life.

PURPOSE: We examined a prospective consecutive cohort of low dose rate (LDR) brachytherapy for prostate cancer to evaluate the efficacy of monotherapy for unfavorable-intermediate risk (UIR) disease, and explore factors associated with toxicity and quality of life (QOL). METHODS: 149 men with prostate cancer, including 114 staged with MRI, received Iodine-125 brachytherapy alone (144-145 Gy) or following external beam radiation therapy (110 Gy; EBRT). Patient-reported QOL was assessed by the Expanded Prostate Index Composite (EPIC) survey, and genitourinary (GU) and gastrointestinal (GI) toxicity were prospectively recorded (CTC v4.0). Global QOL scores were assessed for decline greater than the minimum clinically important difference (MCID). Univariate analysis (UVA) was performed, with 30-day post-implant dosimetry covariates stratified into quartiles. Median follow-up was 63 mo. RESULTS: Men with NCCN low (n = 42) or favorable-intermediate risk (n = 37) disease were treated with brachytherapy alone, while most with high-risk disease had combined EBRT (n = 17 of 18). Men with UIR disease (n = 52) were selected for monotherapy (n = 42) based on clinical factors and MRI findings. Freedom from biochemical failure-7 yr was 98%. Of 37 men with MRI treated with monotherapy for UIR disease, all 36 men without extraprostatic extension were controlled. Late Grade 2+/3+ toxicity occurred in 55/3% for GU and 8/2% for GI, respectively. Fifty men were sexually active at baseline and had 2 yr sexual data; 37 (74%) remained active at 2 yr. Global scores for urinary incontinence (UC), urinary irritation/obstruction (UIO), bowel function, and sexual function (SF) showed decreases greater than the MCID (p < 0.05) in UC at 2 mo, UIO at 2 and 6 mo, and SF at 2-24 mo, and >5 yr. Analysis did not reveal any significant associations with any examined rectal or urethral dosimetry for late toxicity or QOL. CONCLUSION: Disease outcomes and patient-reported QOL support LDR brachytherapy, including monotherapy for UIR disease.

Serum/glucocorticoid-regulated kinase 1 expression in primary human prostate cancers.

BACKGROUND: Serum/glucocorticoid-regulated kinase 1 (SGK1), a known target of the androgen receptor (AR) and glucocorticoid receptor (GR), is reported to enhance cell survival. This study sought to better define the role of SGK1 and GR in prostate cancer. METHODS: Immunohistochemistry was performed for AR, GR, and SGK1 on primary prostate cancers (n = 138) and 18 prostate cancers from patients treated with androgen deprivation therapy. Relative staining intensity was compared utilizing a Fisher's exact test. Univariate analyses were performed using log-rank and chi-squared tests to evaluate prostate cancer recurrence with respect to SGK1 expression. RESULTS: SGK1 expression was strong (3+) in 79% of untreated cancers versus 44% in androgen-deprived cancers (P = 0.003). Conversely, GR expression was present in a higher proportion of androgen-deprived versus untreated cancers (78% vs. 38%, P = 0.002). High-grade cancers were nearly twice as likely to have relatively low (0 to 2+) SGK1 staining compared to low-grade cancers (13.8% vs. 26.5%, P = 0.08). Low SGK1 expression in untreated tumors was associated with increased risk of cancer recurrence (adjusted log-rank test P = 0.077), 5-year progression-free survival 47.8% versus 72.6% (P = 0.034). CONCLUSIONS: SGK1 expression is high in most untreated prostate cancers and declines with androgen deprivation. However, these data suggest that relatively low expression of SGK1 is associated with higher tumor grade and increased cancer recurrence, and is a potential indicator of aberrant AR signaling in these tumors. GR expression increased with androgen deprivation, potentially providing a mechanism for the maintenance of androgen pathway signaling in these tumors. Further study of the AR/GR/SGK1 network in castration resistance.

Continence outcomes in patients undergoing robotic assisted laparoscopic mitrofanoff appendicovesicostomy.

PURPOSE: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. MATERIALS AND METHODS: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). RESULTS: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). CONCLUSIONS: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study.

PURPOSE: Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. MATERIALS AND METHODS: We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). RESULTS: The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001). CONCLUSIONS: The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

Paediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA): feasibility of and initial experience with the University of Chicago technique.

OBJECTIVE: •To present the first series of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendico-vesicostomy (RALIMA) in a paediatric population. PATIENTS AND METHODS: • From February to November 2008, six patients with neurogenic bladder secondary to spina bifida (status post corrective spine surgery) were selected to undergo RALIMA by a single surgeon (MSG) at the University of Chicago Medical Center. • Patients had constipation, day and night-time incontinence, with recurrent urinary tract infection (UTI), and failed attempts at anticholinergic therapy and clean intermittent catheterization. All had low-capacity bladders with poor compliance and high leak point pressures. • Preoperative bowel preparation was not performed. Mean follow-up is 18 months. RESULTS: • One patient required conversion to open ileal augmentation because of failure to progress and another underwent augmentation ileocystoplasty without appendico-vesicostomy. The average age of patients was 9.75 years (range 8-11 years). • Average operative time was 8.4 h (range 6-11 h). There were no intraoperative complications. One patient had a postoperative wound infection, one had a lower extremity venous thrombus, and another had temporary unilateral lower extremity paresthesia that has resolved. Three patients required revision of their stoma at the skin-level. • Perioperatively, patients only required oral analgesia for 24-36 h (excluding one patient with paralytic ileus), started on liquid diet after 7.5 hours (range 6-10 h), on regular diet after 24 h (range 12-36 h) and were discharged home within 7 days. • Postoperatively, patients demonstrated no leak on follow-up cystogram, and were catheterizing per apendico-vesicostomy (three patients by 6 weeks) or urethra (1 patient at 4 weeks). • All patients now have day and night-time continence with no UTIs, and bladder capacity of 250-450 mL. CONCLUSION: • While longer follow-up will be necessary to see if these results are durable, this series demonstrates that RALIMA is a safe, feasible and effective procedure in the short term, with the possible added benefits of reduced analgesia, shorter recovery time and improved aesthetic appearance.

"Robotic fatigue?" - The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy.

PURPOSE: Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially. MATERIALS AND METHODS: A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM. RESULTS: Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 0.761.231.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion. CONCLUSION: Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.

Robotic radical prostatectomy for elderly patients: probability of achieving continence and potency 1 year after surgery.

PURPOSE: We assessed the probability of achieving continence and potency after robotic radical prostatectomy in elderly patients. MATERIALS AND METHODS: The cohort included 1,436 robotic radical prostatectomy cases performed at our institution between 2003 and 2008. Continence (pad-free) and potency (erection sufficient for intercourse) at baseline and 1 year after surgery were evaluated by the UCLA-PCI questionnaire. Point estimates of the predicted probabilities of continence and potency for age 65, 70 and 75 years were calculated from multivariate logistic regression models adjusting for age, nerve sparing status, baseline International Prostate Symptom Score and baseline Sexual Health Inventory for Men score. Patients who were impotent before surgery or those who received hormones or radiation within 1 year after surgery were censored. RESULTS: Mean patient age was 60 years (range 38 to 85) with 25% older than 65 years and 77 (5%) 70 years old or older. Age (OR 0.97, p = 0.002), baseline I-PSS (OR 0.98, p = 0.02) and Sexual Health Inventory for Men scores (OR 1.02, p = 0.005) were independently associated with being pad-free. Age (OR 0.92, p <0.0001), baseline Sexual Health Inventory for Men score (OR 1.1, p <0.0001) and bilateral nerve sparing (OR 2.92, p <0.0001) were independently associated with achieving potency. Predicted probabilities (95% CI) of postoperative 1-year continence at age 65, 70 and 75 years were 0.66 (0.63, 0.69), 0.63 (0.57, 0.68) and 0.59 (0.52, 0.66), respectively. The corresponding probabilities of postoperative 1-year potency after bilateral nerve sparing were 0.66 (0.62, 0.71), 0.56 (0.49, 0.64) and 0.46 (0.36, 0.56). CONCLUSIONS: In our experience there is an acceptable probability of achieving continence and potency after robotic radical prostatectomy in selected elderly patients.

Intraoperative frozen section assessment of pelvic lymph nodes during radical prostatectomy is of limited value.

OBJECTIVE: To evaluate the accuracy of frozen section (FS) assessment of pelvic lymph nodes (PLNs) during radical prostatectomy (RP) in a large contemporary cohort; and to analyse the contribution of FS to surgical decision making in this setting. PATIENTS AND METHODS: During a 4-year period at a single institution, RPs with PLN dissection (PLND) were reviewed. The number and size of the PLNs, and the size of metastases were measured. RESULTS: FS was performed on 349 bilateral PLNDs. Overall, 28 (8%) cases were positive for metastasis, 11 of which were detected by FS (39%). The 17 false negatives, all of which contained metastases smaller than 5 mm, were due to failure to identify and freeze the positive PLNs (11), failure to section at the level of the metastatic tumour (four), or interpretative error (two). The sensitivity was not affected by the number of sampled nodes. The size of metastasis was the determining factor for the accuracy of FS, with metastases of ≥ 5 mm having a sensitivity of 100%, and metastases of < 5 mm having a sensitivity of 10%. Among the 11 true positives, RP was aborted in eight cases and continued in three. During the same period, 261 PLNDs were performed without FS, and 18 (6.9%) had metastases. CONCLUSIONS: FS is highly accurate in detecting large, grossly evident metastases, but performs poorly on micrometastases. It is recommended that a two-step approach applied to routine FS starting with a careful gross examination followed by FS for only grossly suspicious PLNs.

Length of positive surgical margin after radical prostatectomy as a predictor of biochemical recurrence.

PURPOSE: Length and location of positive surgical margins are independent predictors of biochemical recurrence after open radical prostatectomy. We assessed their impact on biochemical recurrence in a large robotic prostatectomy series. MATERIALS AND METHODS: Data were collected prospectively from 1,398 men undergoing robotic radical prostatectomy for clinically localized prostate cancer from 2003 to 2008 at a single institution. The associations of preoperative prostate specific antigen, pathological Gleason score, pathological stage and positive surgical margin parameters (location, length and focality) with biochemical recurrence rate were evaluated. Margin status and length were measured by a single uropathologist. Biochemical recurrence was defined as serum prostate specific antigen greater than 0.1 ng/ml on 2 consecutive tests. Cox regression models were constructed to evaluate predictors of biochemical recurrence. RESULTS: Of 1,398 consecutive patients who underwent robotic prostatectomy positive margins were present in 243 (17%) (11% of pathological T2 and 41% of T3). Preoperative prostate specific antigen, pathological stage, Gleason score, margin status, and margin length as a continuous and categorical variable (less than 1, 1 to 3, more than 3 mm) were independent predictors of biochemical recurrence. Patients with negative margins and those with a positive margin less than 1 mm had similar rates of biochemical recurrence (log rank test p = 0.18). Surgical margin location was not independently associated with biochemical recurrence. CONCLUSIONS: Margin status and length are independent predictors of biochemical recurrence following robotic radical prostatectomy. Although longer followup and validation studies are necessary for confirmation, patients with a positive margin less than 1 mm appear to have similar recurrence rates as those with negative margins.

Adjuvant chemotherapy in lymph node positive bladder cancer.

OBJECTIVES: Lymph node-positive bladder cancer is a systemic disease in the majority of patients. Adjuvant chemotherapy given shortly after surgery, when tumor burden is low, seems reasonable, yet there is no proof that it improves survival. In this retrospective study, we compare the outcomes of patients with microscopic lymph node positive bladder cancer (pN1 or pN2) treated with radical cystectomy followed by adjuvant chemotherapy and those who declined chemotherapy. METHODS: Sixty-seven patients with lymph node positive bladder cancer (26 pN1 and 41 pN2) who underwent radical cystectomy between April 1995 and April 2005 were reviewed. Combined adjuvant chemotherapy (gemcitabine and cisplatin in most patients) was given to 35 patients (52%), but declined by 32 (48%). The two groups were similar in performance status, postoperative complication rate, and N stage but deferring patients were on average 5 years older and had a more advanced T stage. Study primary endpoint was overall survival (OS). RESULTS: Adjuvant chemotherapy was well tolerated and 28/35 patients (80%) completed all 4 cycles. Median OS of patients given adjuvant chemotherapy was 48 months compared with 8 months for declining patients (hazard ratio 0.13, 95% CI 0.04-0.4, P < 0.0001). Multivariate age adjusted analysis showed that adjuvant chemotherapy was an independent factor affecting OS (hazard ratio 0.2, P < 0.0001). CONCLUSION: This study supports the use of adjuvant chemotherapy after radical cystectomy in patients with node positive bladder cancer. Study design and patient imbalances make it impossible to draw definitive conclusions.

Total laparorobotic repair of abdominal aortic aneurysm with sac exclusion obliteration and aortobifemoral bypass.

A 65-year-old man with coronary artery disease, hypertension, and peripheral vascular disease was found to have an asymptomatic abdominal aortic aneurysm (AAA) of 5.5 cm on surveillance for his peripheral vascular disease. Cardiac stress testing demonstrated no evidence of myocardial ischemia, and he opted to undergo open repair of his aneurysm. Laparorobotic repair of the infrarenal AAA using the da Vinci robotic system was performed with an aortobifemoral bypass. We describe a novel technique for AAA exclusion using a cerclage method, which greatly facilitates repair of infrarenal AAAs using laparorobotic techniques. Laparorobotic repair of infrarenal AAA can be greatly facilitated by AAA sac exclusion and obliteration without the need to ligate all lumbar arteries or to open the aneurysm. This virtually avoids blood loss from the sac and minimizes the possibility for open conversion as a result of poor visualization. Minimally invasive aortic intervention for aneurysmal disease using laparascopic methods has been reported in the literature. Problems associated with this technique include a prolonged learning curve and difficulty completing intracorporeal anastomoses. Robotic surgery provides an advantage over laparoscopic surgery in its ability to provide greater degrees of freedom in a relatively small field of view along with superior high-definition, three-dimensional visualization. To date, there have been no known reports of using robotic surgery in the United States as a sole method for repair of AAA. We report our technique of combining robotic surgery with a novel procedure for sac exclusion and obliteration to successfully repair AAA without the need for opening the aneurysm sac and endoaneurysmorrhaphy.

Serum creatinine can be used as a surrogate for glomerular filtration rate in single renal unit models.

BACKGROUND AND PURPOSE: Single renal unit models are invaluable for studies in renal physiology, transplantation and response to ischemic injury. Glomerular filtration rate (GFR) is commonly used for evaluation of renal function. Measuring the GFR involves relatively complicated and expensive systems. In this study we determined whether serum creatinine (Scr) can predict the GFR in this model. MATERIALS AND METHODS: Right laparoscopic nephrectomy was performed in 46 female pigs weighing 25 kg-30 kg. Twelve days later the left kidney was exposed to various periods of warm ischemia (30, 60, 90, and 120 minutes). Scr and GFR (using the iohexol clearance method) were determined preoperatively and at postoperative days 1, 3, 8, 15, 22 and 29. A total of 244 pairs of Scr and GFR values were analyzed to determine a formula for predicting GFR (pGFR) from Scr. RESULTS: Scr range was 1.2 mg/dl -29 mg/dl and GFR range was 1.8 ml/min -180.5 ml/min. The empiric formula deduced from the database for calculating pGFR from Scr was: pGFR = (217 divided by Scr) minus 0.2. pGFR correlated well with the actual GFR (R(2) = 0.85). The graphs for pGFR were almost indistinguishable from the graphs for actual GFR in every single animal. The results and conclusions of the experiments using either actual or predicted GFR were identical. CONCLUSIONS: We conclude that in a single renal unit porcine model using ischemia as the insult to the kidney, expensive actual measurements of GFR can be reliably replaced by Scr based calculated GFR.