Secondary Urethral Malignancies Following Prostate Brachytherapy.

OBJECTIVE: To understand urethral secondary malignancies among patients treated with brachytherapy (BRT) for primary prostate cancer. PATIENTS AND METHODS: Institutional retrospective review identified 13 patients evaluated from 2003 to 2014 with urethral cancer and history of BRT monotherapy for prostate cancer. All patients were biochemically free of their primary disease and radiation-associated secondary malignancies (RASMs) were confirmed pathologically to be histologically distinct from primary tumor. BRT characteristics, patient age, presentation, staging workup, and clinical course were evaluated. RESULTS: The mean time from BRT to presenting symptoms of hematuria, urinary retention, and/or renal failure was 71 months. Symptom onset to RASM diagnosis interval was 24 months. Mean time from BRT to RASM diagnosis was 95 months. Eighty-five percent of patients had an undetectable prostate-specific antigen level (<0.2 ng/mL) at last follow-up. Types of RASM included sarcomatoid carcinoma (6), small cell carcinoma (2), urothelial carcinoma with squamous differentiation (2), squamous cell carcinoma (1), rhabdomyosarcoma (1), and urothelial carcinoma (1). A majority of patients were diagnosed with advanced disease with either distant metastases (54%) or local progression (23%). Ten patients died during this study period with median time to death after RASM diagnosis of 6 months. CONCLUSION: RASMs localized to the posterior urethra displayed advanced disease and high mortality rates. Refractory lower urinary tract symptoms, hematuria, and history of prostate BRT should raise suspicion for urethral RASMs. Further studies are warranted to determine patient and disease characteristics that correlate with disease-specific mortality of secondary urethral malignancies.

Trends in Renal Transplantation Rates in Patients with Congenital Urinary Tract Disorders.

PURPOSE: Improved bladder and renal management benefit patients with congenital uropathy and congenital pediatric kidney disease. This may translate to delayed initial renal transplantation in these patients, and improved graft and patient survival. Our primary study purpose was to determine whether patients with congenital uropathy and congenital pediatric kidney disease have demonstrated later time to first transplantation and/or graft survival. MATERIALS AND METHODS: SRTR (Scientific Registry of Transplant Recipients) was analyzed for first renal transplant and survival data in patients with congenital uropathy and congenital pediatric kidney disease from 1996 to 2012. Congenital uropathy included chronic pyelonephritis/reflux, prune belly syndrome and congenital obstructive uropathy. Congenital pediatric kidney disease included polycystic kidney disease, hypoplasia, dysplasia, dysgenesis, agenesis and familial nephropathy. RESULTS: A total of 7,088 patients with congenital uropathy and 24,315 with congenital pediatric kidney disease received a first renal transplant from 1996 to 2012. A significant shift was seen in both groups toward older age at initial renal transplantation in those 18 through 64 years old. In the congenital uropathy group this effect was most facilitated by decreased renal transplantion in patients between 18 and 35 years old (38% in 1996 vs 26% in 2012). The congenital pediatric kidney disease group showed a substantial decrease in patients who were 35 to 49 years old (from 39% to 29%). At 10-year followup the congenital uropathy group showed better graft and patient survival than the congenital pediatric kidney disease group. However, aged matched comparison revealed comparable survival rates in the 2 groups. CONCLUSIONS: Analysis of trends in the last 14 years demonstrated that patients with both lower and upper tract congenital anomalies experienced delayed time to the first renal transplant. Furthermore, patients had similar age matched graft and patient survival whether the primary source of renal demise was the congenital lower or upper tract. These findings may indicate that improved urological and nephrological care are promoting renal preservation in both groups.

Gunshot wounds to the lower urinary tract: a single-institution experience.

BACKGROUND: This study aimed to analyze characteristics and outcomes of gunshot wounds to the lower urinary tract at our Level I trauma center. Our hypothesis is that gunshot wounds to the lower urinary tract have characteristic bullet trajectories, injury patterns, and associated injuries. METHODS: Our prospective trauma database was composed of reviewed gunshot wounds to the lower urinary tract including the pelvic ureter, bladder, or urethra from 1989 through 2011. RESULTS: We identified 50 patients (median age, 25 years; range, 3-53 years) with lower urinary tract injury. There was a mean of 2.3 bullets per patient (range, 1-8), with 26 patients injured from a single bullet. Urologic injury involving only the bladder occurred in 72% (36 of 50) of the patients. Ureteral injury was diagnosed in 20% (10 of 50) of the patients. Bullet trajectory was known in the majority of multiple bullet injuries and all cases involving a single bullet.All patients but one were managed operatively. During exploration, 90% (34 of 38) with transmural bladder injury had recognized bladder entry and exit wounds. Overall, 80% (40 of 50) had concurrent gastrointestinal injury. In patients with a single gunshot wound to the lower urinary tract, 58% (15 of 26) sustained concomitant intestinal injury, and 23% (6 of 26) sustained rectal injury.Of 20 posteroanterior gunshot wounds, 80% had buttock entry. All 10 single-bullet buttock-entry gunshot wounds injured the bladder. Isolated ureteral injury was associated with lower abdominal entry and anteroposterior trajectory. Urethral injury occurred in 4, with 75% upper-thigh entry. CONCLUSION: Penetrating injuries to the lower urinary tract most commonly involve the bladder. During exploration for gunshot wounds to the bladder, two injury sites should be expected because failure to close may lead to complications. Gunshot wounds to the lower urinary tract often occur with concomitant bowel injury, with buttock entry. A multidisciplinary approach involving general surgery is imperative. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Prostate size is not associated with recovery of sexual function after minimally invasive radical prostatectomy.

OBJECTIVES: To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy. METHODS: Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis. RESULTS: Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point. CONCLUSIONS: Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy.

Status of endoscopes and instruments used during NOTES.

Natural orifice translumenal endoscopic surgery (NOTES) requires an intentional perforation of a hollow lumen to pass an endoscope into an otherwise inaccessible body cavity with diagnostic or therapeutic intent. The limitations of current flexible instruments for this purpose are outlined, including the unsuitability for NOTES of current flexible needle knives, guidewires, balloons, overtubes, grasping forceps, and scissors. The development of novel suturing instruments, trocars, articulating instruments, flexible bipolar forceps, flexible clips, magnetic devices, and staplers as well as the advent of manual mechanical manipulators for flexible accessories is outlined. New instrument solutions for endosurgery are described, such as articulating flexible accessories for gastroscopes, novel "platforms" that can be rigidized, and unconventional scope arrangements. Debatably, the greatest current benefit of NOTES is that it may lead to further development of better instrumentation for endosurgery.

Urethral carcinosarcoma from bladder carcinosarcomatous lesions: analysis of clinicopathological features.

Carcinosarcoma (CS) of the bladder is a rare malignancy of the genitourinary tract that is highly aggressive with unfavorable prognoses. Data regarding the epidemiological and clinicopathological characteristics of CS of the urinary bladder have been limited due to the low reported incidence of the tumor. In particular, there is little evidence on recurrence patterns and surveillance after definitive surgical therapy. In this case report, we describe a urethral recurrence of CS after radical cystoprostatectomy for CS of the bladder. The goal of this case report is to review our current understanding of the pathological and recurrence patterns of patients with CS of the urinary bladder in order to better define postoperative care for patients with CS of the bladder.

The impact of prostate size on urinary quality of life indexes following laparoscopic radical prostatectomy.

PURPOSE: We assessed the effects of prostate size on long-term health related quality of life and functional outcomes after laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 729 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer were stratified by pathological prostate gland weight, including group 1--less than 35 gm, group 2--35 to 70 gm and group 3--greater than 70 gm. Urinary health related quality of life was assessed preoperatively and at regular intervals following laparoscopic radical prostatectomy using the validated Expanded Prostate Cancer Index Composite questionnaire. RESULTS: A total of 613 evaluable patients were studied with a mean age of 57.7 years, a preoperative prostate specific antigen of 6.0 ng/ml, a median preoperative and postoperative Gleason score of 6, and a mean pathological gland weight of 51.3 gm (range 13.4 to 145.7). Patients with the largest glands had significantly worse baseline urinary function, as demonstrated by Expanded Prostate Cancer Index Composite urinary domain summary (p <0.001) and subscale scores, including scores for urinary bother (p <0.001), urinary irritative/obstructive (p = 0.001) and urinary incontinence (p = 0.03). Patients in group 3 also had significantly older age, a higher body mass index, longer operative time and more blood loss (each p <0.05). Despite preoperative differences and possible confounders all groups approached similar urinary health related quality of life outcomes at all time points postoperatively. At 12 months patients with the largest glands had improved Expanded Prostate Cancer Index Composite urinary irritative/obstructive and urinary bother subscale scores compared to their baseline scores (p <0.05). CONCLUSIONS: In laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not associated with delayed or worse postoperative urinary health related quality of life. Furthermore, in patients with large glands an improvement in urinary irritative/obstructive and bother symptoms from baseline may be seen 12 months postoperatively.

Laparoscopic treatment of simultaneous tumors in the liver and kidney.

BACKGROUND/AIMS: To report our experience with laparoscopic treatment of liver tumors during right-sided transperitoneal laparoscopic nephrectomy. METHODS: Two patients undergoing transperitoneal laparoscopic radical nephrectomy on the right side each had a concomitant tumor in the right lobe of the liver. The first patient was incidentally found to have a lesion suspicious for metastatic disease. The second had a known asymptomatic giant hemangioma of the liver. RESULTS: Total operative time was 130 and 101 min. Estimated blood loss was 400 and 300 ml. There were no complications. The first patient had bilateral papillary renal cell carcinoma and concomitant fibroadipose tissue within the liver. The second patient presented with clear cell carcinoma of the right kidney and a cavernous hemangioma of the liver. CONCLUSIONS: When indicated, simultaneous right-sided kidney and liver tumors may be treated by a combined laparoscopic transperitoneal approach. Laparoscopic expertise is advised.

Laparoscopic heminephrectomy for renal cell carcinoma in cross-fused ectopic kidney.

Crossed renal ectopia is a rare congenital malformation. We report a case of renal cell carcinoma in a 51-year-old man with right-to-left crossed fused renal ectopia. The patient was treated with ultrasound-guided laparoscopic heminephrectomy. Postoperative three-dimensional computed tomography showed normal perfusion of the remaining part of the kidney, with good excretion of contrast from both units of the cross-fused kidney.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection: evaluation of complications.

OBJECTIVES: Initial publications on postchemotherapy laparoscopic retroperitoneal lymph node dissection (LRPLND) have described significant intraoperative and postoperative morbidities. This report reviewed the complication rate with additional experience. METHODS: A retrospective review of the medical records of 16 consecutive patients who underwent postchemotherapy LRPLND by a single surgeon from September 1996 to September 2005 was performed. The evaluation included tumor type, clinical stage, pathologic stage, and intraoperative and postoperative complications. RESULTS: Postchemotherapy LRPLND was successfully performed in 14 (87.5%) of 16 patients. Seven patients (43.8%) developed complications and 2 (12.5%) required open conversion. The most complications occurred during the postoperative period and were classified as minor. Of the total patient population, 25% had minor postoperative complications. The median hospital stay was 2 days. No patient who underwent the procedure died. All intraoperative complications were vascular injuries and occurred during the first half of the series (1996 to 2000). In the second half of the series (2000 to 2005), no complications during the operative period and no vascular or major complications occurred. No retroperitoneal recurrence was noted during a mean follow-up of 32.7 months (range 5 to 108). One patient developed distant recurrence and underwent successful salvage chemotherapy. CONCLUSIONS: Postchemotherapy LRPLND remains a challenging, but feasible, operation. With greater experience, the incidence of complications and morbidity can be reduced.

Complications of 2,775 urological laparoscopic procedures: 1993 to 2005.

PURPOSE: We assessed the complications associated with urological laparoscopic surgery at a single high volume center during a 12-year period. MATERIALS AND METHODS: A retrospective chart analysis was performed, focusing on complications associated with 2,775 laparoscopic surgeries occurring between 1993 and 2005. These included radical nephrectomy (549), partial nephrectomy (345), donor nephrectomy (553), simple nephrectomy (186), pyeloplasty (301), nephroureterectomy (105), retroperitoneal lymph node dissection (86), renal ablation (81), adrenalectomy (106) and radical prostatectomy (463). Complication data were tabulated according to case number, procedure type, patient age, the American Society of Anesthesiologists score, conversion status, length of hospitalization, Clavien classification system and annual complication rate during the study. Statistical analysis was performed with Fisher's exact and chi-square tests. RESULTS: A total of 614 complications (22.1%) occurred within each group, broken down into laparoscopic radical nephrectomy (20%), laparoscopic partial nephrectomy (28%), laparoscopic donor nephrectomy (28%), laparoscopic simple nephrectomy (15%), laparoscopic pyeloplasty (13.3%), laparoscopic nephroureterectomy (40.9%), laparoscopic retroperitoneal lymph node dissection (26.7%), laparoscopic renal tumor ablation (18.6%), laparoscopic adrenalectomy (25.4%) and laparoscopic radical prostatectomy (15%). Total intraoperative and postoperative complication rates were 4.7% and 17.5%, respectively. Vascular injuries were the most common intraoperative complications. Annual complication rates plateaued in the year 2000 and were not significantly different during the ensuing 4 years (p >0.05). Complications correlated with a greater American Society of Anesthesiologists score as well as a longer hospital stay (p <0.05). CONCLUSIONS: The data presented here help define the complication rates for laparoscopic urological procedures in experienced hands at a high volume institution.

Magnetic resonance imaging compatible robotic system for fully automated brachytherapy seed placement.

OBJECTIVES: To introduce the development of the first magnetic resonance imaging (MRI)-compatible robotic system capable of automated brachytherapy seed placement. METHODS: An MRI-compatible robotic system was conceptualized and manufactured. The entire robot was built of nonmagnetic and dielectric materials. The key technology of the system is a unique pneumatic motor that was specifically developed for this application. Various preclinical experiments were performed to test the robot for precision and imager compatibility. RESULTS: The robot was fully operational within all closed-bore MRI scanners. Compatibility tests in scanners of up to 7 Tesla field intensity showed no interference of the robot with the imager. Precision tests in tissue mockups yielded a mean seed placement error of 0.72 +/- 0.36 mm. CONCLUSIONS: The robotic system is fully MRI compatible. The new technology allows for automated and highly accurate operation within MRI scanners and does not deteriorate the MRI quality. We believe that this robot may become a useful instrument for image-guided prostate interventions.

Pure laparoscopic radical nephrectomy with level II vena caval thrombectomy.

Continued experience with the laparoscopic technique has allowed for controlled resection of renal neoplasms invading the renal vein and inferior vena cava. We present the case of a patient with a primary renal tumor extending into the vena cava that was completely managed with a laparoscopic approach.

Laparoscopic versus open partial nephrectomy for the treatment of pathological T1N0M0 renal cell carcinoma: a 5-year survival rate.

PURPOSE: We retrospectively compared the oncological adequacy of laparoscopic partial nephrectomy to that of open partial nephrectomy in the treatment of patients with pathological stage T1N0M0 renal cell carcinoma. MATERIALS AND METHODS: A total of 143 patients with stage T1N0M0 renal tumors confirmed by pathological examination of the surgical specimen underwent partial nephrectomy between January 1996 and June 2004 with a followup of at least 1.5 years. Of these patients 85 were treated laparoscopically and the remaining 58 underwent open surgery. Medical and operative records were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical analysis was performed using Kaplan-Meier analysis. RESULTS: The mean followup for the laparoscopy group was 40.4 +/- 18.0 months. A total of 83 patients survived. Of these patients 2 patients experienced disease recurrence within 18 to 46.2 months, 1 patient died of cancer metastasis to brain within 29.7 months and 1 died of an unrelated cause. Seeding of the port sites did not develop in any of the patients. The 5-year disease-free and actuarial survival rates for this group were 91.4%, and 93.8%, respectively. The 58 patients who underwent open surgery had a mean followup of 49.68 +/- 28.84 months. A total of 53 patients survived without any disease recurrence, 1 survived with recurrence within 8 months, 1 survived with metastasis within 49 months and 3 died of unrelated causes. The 5-year disease-free and patient survival rates for this group were 97.6% and 95.8%, respectively. Kaplan-Meier disease-free survival and patient survival analysis revealed no significant differences between the laparoscopic and open partial nephrectomy groups. CONCLUSIONS: Laparoscopic partial nephrectomy is an alternative technique with mid-range oncological results comparable to open partial nephrectomy in patients with localized pathological stage T1N0M0 renal cell carcinoma.

Prophylactic gelatin sponge tract injection to prevent bleeding after percutaneous renal cryoablation in a swine model.

PURPOSE: Achievement of hemostasis can be a challenge during percutaneous renal cryoablation (PRC). This study describes the use of a porcine model to test the ability of gelatin sponge injection into the tract to limit bleeding at the site of cryoprobe puncture. MATERIALS AND METHODS: A total of nine swine (18 kidneys) underwent bilateral ultrasound-guided PRC with double freeze/thaw cycle protocol with use of a 2.4-mm cryoprobe. The cryoablation location and protocol were applied identically to both kidneys in each pig; however, only one side received gelatin sponge injection after cryoablation through a coaxial sheath (3 mm). After removal of the sheath, a midline laparotomy incision was performed and sponges were placed around the kidneys. Blood loss was measured by calculating the change in weight of the sponges after 30 minutes of absorption time. Acute blood loss was compared between the two groups. The kidneys treated with gelatin sponge were removed and grossly and histologically examined to identify the gelatin sponge at the puncture cryolesion. RESULTS: The use of gelatin sponge resulted in significantly less blood loss (mean, 8.24 mg +/- 4.68) compared with the control kidneys (mean, 20.24 mg +/- 8.14; P = .001). Gross and histopathologic results confirmed that the gelatin sponge was in the cryoablation puncture sites. Mean diameters of cryoablation ice balls on the gelatin sponge and control sides were 3.9 cm +/- 0.2 and 3.8 cm +/- 0.4, respectively. The lesions were not significantly different between sides. CONCLUSION: Percutaneous tract injection of gelatin sponge appears promising as a method to decrease acute blood loss from PRC.

Trends in the operative management of renal tumors over a 14-year period.

OBJECTIVE: To review the trends in the operative management of renal tumours over a 14-year period at a university hospital, as the therapeutic options available for treating renal tumours have increased over the past decade. PATIENTS AND METHODS: The study was a retrospective chart review of 1621 consecutive patients undergoing treatment for renal tumours from January 1991 to March 2005. The characteristics assessed included patient demographics, tumour size, operative duration and treatment. RESULTS: During the study period, 624 (38.6%) open, 883 (54.6%) laparoscopic and 111 (6.7%) percutaneous approaches were performed. The number of renal tumours treated increased annually, as did the use of minimally invasive techniques (93.4% in 2005). Conversely, the number of open surgical treatments used declined both absolutely and proportionally. Over the study period, for tumours of 7 cm, open radical nephrectomy (ORN) was the most common method of treatment over all years. However, since 2002, laparoscopic radical nephrectomy (LRN) surgery has been increasingly used over ORN for treating this tumour group (73% LRN vs 19.2% ORN in 2004). CONCLUSION: The available treatment options for renal tumours have increased significantly since the early 1990s. At a university hospital in which there are physicians with a specific interest in minimally invasive surgery and ablative treatments, minimally invasive approaches have become the standard treatment.