Laparoscopic Radical Prostatectomy with a Remote Controlled Robot.

PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Long-term analysis of oncological outcomes after laparoscopic radical cystectomy in Europe: results from a multicentre study by the European Association of Urology (EAU) section of Uro-technology.

OBJECTIVE: To report long-term outcomes of laparoscopic radical cystectomy (LRC) in a multicentre European cohort, and explore feasibility and safety of LRC. PATIENTS AND METHODS: This study was coordinated by European Association of Urology (EAU)-section of Uro-technology (ESUT) with nine centres enrolling 503 patients undergoing LRC for bladder cancer prospectively between 2000 and 2013. Data were retrospectively analysed. Descriptive statistics were used to explore peri- and postoperative characteristics of th ecohort. Kaplan-Meier curves were constructed to evaluate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Outcomes were also stratified according to tumour stage, lymph node (LN) involvement and surgical margin status. RESULTS: Minor complications (Clavien I-II) occurred in 39% and major (IIIa-IVb) in 17%. In all, 10 (2%) postoperative deaths were recorded. The median (interquartile, IQR) LN retrieval was 14 (9-17) and positive surgical margins were detected in 29 (5.8%) patients. The median (mean, IQR) follow-up was 50 (60, 19-90), during which 134 (27%) recurrences were detected. Actuarial RFS, CSS and OS rates were 66%, 75% and 62% at 5 years and 62%, 55%, 38% at 10 years. Significant differences in RFS, CSS and OS were found according to tumour stage, LN involvement and margin status (log-rank P < 0.001). On multivariate Cox analysis, T stage and LN involvement (both P < 0.001) were significant predictors of RFS, CSS and OS. Positive margins were significant predictors of RFS (P = 0.016) and CSS (P = 0.043). CONCLUSIONS: In this European LRC multicentre study, the largest to date, long-term RFS, CSS and OS rates after LRC appear comparable to those reported in current open RC series. Further randomised controlled trials are necessary to assess the global impact of LRC.

Neurophysiological testing to assess penile sensory nerve damage after radical prostatectomy.

INTRODUCTION: Radical prostatectomy (RP) can lead to erectile dysfunction due to surgical injury of the cavernous nerves. However, there is no simple, objective test to evaluate cavernous nerve damage caused by RP in clinical practice. AIM: To assess the value of the measurement of penile thermal and vibratory sensory thresholds to reflect cavernous nerve damage caused by RP. METHODS: We included 42 consecutive patients who underwent RP with cavernous nerve sparing (laparoscopic approach, N = 12) or without cavernous nerve sparing (laparoscopic, N = 13; retropubic, N = 11; or transperineal, N = 6). Penile thermal (warm and cold) and vibratory sensory thresholds were measured twice, together with the Erectile Dysfunction Symptom Score (EDSS), 1 month before and 2 months after RP. MAIN OUTCOME MEASURES: Penile sensory thresholds for warm, cold, and vibration sensations. RESULTS: Penile sensory thresholds for warm (P < 0.0001) and cold (P < 0.0001) sensations significantly increased after non-nerve-sparing RP, but not after nerve-sparing RP. Vibration threshold only increased after transperineal non-nerve-sparing RP (P = 0.031). EDSS values were significantly increased in all groups of patients 2 months after surgery. CONCLUSIONS: Sensory nerve fibers carrying penile skin sensations travel with the cavernous nerves in the pelvis. Therefore, testing these sensations may help to evaluate the extent of cavernous nerve damage caused by RP. In this series, post-operative changes in penile sensory thresholds differed with the surgical technique of RP, as the cavernous nerves were preserved or not. The present results support the value of quantitative penile sensory threshold measurement to indicate RP-induced cavernous nerve injury.

The prostate cancer gene 3 (PCA3) urine test in men with previous negative biopsies: does free-to-total prostate-specific antigen ratio influence the performance of the PCA3 score in predicting positive biopsies?

OBJECTIVE: to determine the performance characteristics of the prostate cancer gene 3 (PCA3) score on the outcome of biopsy relative to different ranges of free-to-total prostate-specific antigen (PSA) ratio (f/tPSA) in men with a previous negative biopsy and a PSA level of 2.5-10 ng/mL, as urine tests like PCA3 are currently under investigation in order to improve prostate cancer diagnosis and to decrease the rate of unnecessary rebiopsies. PATIENTS AND METHODS: data from the previous prospective European multicentre study were reviewed. Only patients with a PSA level of 2.5-10 ng/mL were included in the present study. In all, 301 patients had complete data. The diagnostic accuracy of the PCA3 score for predicting a positive biopsy outcome was studied using sensitivity, specificity, negative and positive predictive values. The PCA3 performance was evaluated relative to three different subgroups of f/tPSA, as follows: >20% (group 1), 10-20% (group 2) and <10% (group 3). RESULTS: the prostate cancer detection rates were 18.8%, 23.9% and 34.8% in groups 1, 2 and 3, respectively. The area under the receiver operating characteristic curve of the PCA3 score, total PSA and f/tPSA was 0.688, 0.553 and 0.571, respectively. The percentage of men with positive biopsies was 30.6%, 37.0% and 44.4% in those with a PCA3 score of >30, vs 10.3%, 15.5% and 28.6% when the PCA3 score was <30, in groups 1, 2 and 3, respectively. The difference was significant only in groups 1 and 2. In men with a f/tPSA of ≤ 10% the difference in detection rates relative to the PCA3 score was not statistically significant regardless of which PCA3 threshold was used. A high PCA3 score was significantly associated with age, clinical T2 stage and positive biopsy (P < 0.001, 0.013 and <0.001, respectively). In bivariate analysis accounting for the PCA3 score and the f/tPSA, a PCA3 score of >30 was a significant independent predictor of positive biopsies (odds ratio 3.01; 95% confidence interval 1.74-5.23; P < 0.001). CONCLUSIONS: PCA3 remained a better predictor of prostate cancer than f/tPSA. In men with a f/tPSA of >10%, the use of the PCA3 score was highly correlated with the risk of having cancer on re-biopsy, and could prevent unnecessary prostate biopsies if the value is low.

Tumor size does not predict risk of metastatic disease or prognosis of small renal cell carcinomas.

PURPOSE: We characterized the clinicopathological features and the prognosis of small solid renal tumors defined as tumors 4 cm or smaller. MATERIALS AND METHODS: We identified 1,208 patients who were treated with nephrectomy at 5 international academic centers for small solid renal tumors. Clinicopathological parameters and outcome data were collected for each patient and analyzed. RESULTS: Of the tumors 88% were renal cell carcinoma and 12% were benign. Of those with renal cell carcinoma 995 (93%) were localized (N0M0) and 72 (7%) presented with metastatic disease. Tumor size did not predict synchronous metastatic disease. The incidence of metastatic disease in the tumor size ranges 0.1 to 1.0, 1.1 to 2.0, 2.1 to 3.0 and 3.1 to 4.0 cm was 7%, 6%, 5% and 8%, respectively (p = 0.322). Survival rates were excellent. The majority of patients who died of renal cell carcinoma (54%) presented with synchronous metastatic disease, but 3% of patients with localized disease also died of renal cell carcinoma. In patients with localized disease there was a 7% chance of recurrence post nephrectomy at 5 years. Progression-free survival (28 months) was better than for patients with metastatic disease having a primary tumor greater than 4 cm (8 months). Tumor size was not retained as an independent prognostic factor of survival in multivariate analyses. The University of California Integrated Staging System and the Karakiewicz nomogram were the best predictors of cancer specific survival for all renal cell carcinoma stages (c-index 0.87). CONCLUSIONS: More than 85% of small solid renal tumors are renal cell carcinoma. The majority of localized small renal tumors can be cured with existing surgical approaches. However, there is a small but not insignificant risk of synchronous and metachronous metastatic disease and cancer associated death. Patients considering experimental therapies such as ablation and surveillance should be aware of this. Tumor size alone is not sufficient to distinguish renal cell carcinoma with benign behavior from aggressive small renal cell carcinoma. Survival of patients with small metastatic renal cell carcinoma is better then expected. The biology of these unique tumors should be further studied.

Introducing a prognostic score for pretherapeutic assessment of seminal vesicle invasion in patients with clinically localized prostate cancer.

PURPOSE: To identify prostate cancer patients who will have the most likely benefit from sparing the seminal vesicles during 3D conformal radiation therapy. METHODS AND MATERIALS: From 1988 to 2001, 532 patients underwent radical prostatectomy for clinically localized prostate cancer. Primary endpoint was the pathological evidence of seminal vesicle invasion. Variables for univariate and multivariate analyses were age, prostate weight, clinical stage, PSA level, Gleason score, number and site of positive prostate sextant biopsies. Multivariate logistic regression with backward stepwise variable selection was used to identify a set of independent predictors of seminal vesicle invasion, and the variable selection procedure was validated by non-parametric bootstrap. RESULTS: Seminal vesicle invasion was reported in 14% of the cases. In univariate analysis, all variables except age and prostate weight were predictors of seminal vesicle invasion. In multivariate analysis, only the number of positive biopsies (P<0.0001), Gleason score (P<0.007) and PSA (P<0.0001) were predictors for seminal vesicles invasion. Based on the multivariate model, we were able to develop a prognostic score for seminal vesicle invasion, which allowed us to discriminate two patient groups: A group with low risk of seminal vesicles invasion (5.7%), and the second with a higher risk of seminal vesicles invasion (32.7%). CONCLUSIONS: Using the number of positive biopsies, Gleason score and PSA, it is possible to identify patients with low risk of seminal vesicles invasion. In this population, seminal vesicles might be excluded as a target volume in radiation therapy of prostate cancer.

Profiles of the 2 INK4a gene products, p16 and p14ARF, in human reference urothelium and bladder carcinomas, according to pRb and p53 protein status.

The INK4a/ARF locus encodes 2 cell cycle regulatory proteins: p16 and p14(ARF). P16 inhibits the activities of cdks, which maintain the retinoblastoma protein (pRb) in its active hypophosphorylated state. P14(ARF) blocks MDM2-induced p53 degradation and transactivational silencing. In this study, we investigated the expression of p16 and p14(ARF) in reference human urothelium and in 51 urothelial carcinomas (UCs) of all stages and grades, by reverse transcription-polymerase chain reaction (RT-PCR). Patterns of p14(ARF) and p16 expression were compared with each other and then with patterns of p53 and pRb protein expression, respectively, as determined by immunohistochemistry. P14(ARF) and p16 mRNAs were present at low levels or were undetectable in reference urothelia and in most superficial tumors, whereas they were present at high levels in a subset of tumors of advanced stage and high grade. The expression profiles of these 2 mRNAs were correlated in all but 4 cases, indicating that the 2 INK4a products may have nonredundant functions. Forty-six of the 51 tumors (90%) presented changes to or a lack of activation of the p14(ARF)-p53 pathway and were p53 positive (n = 10), p14(ARF) negative (n = 23), or both p53 positive and p14(ARF) negative (n = 13), suggesting that these 2 components of the pathway may be altered or nonactivated. Markedly high levels of p16 mRNA (n = 5) were associated with the absence of pRb expression, with the exception of 1 case in which the p16 gene contained a deletion mutation. A lack of p16 mRNA or low levels of this mRNA were associated with pRb detection in all but 1 case. In invasive UCs, the p16-pRb pathway, the p14(ARF)-p53 pathway, or in many cases both pathways were altered or not activated, demonstrating the involvement of these pathways in invasive bladder tumorigenesis.

Robotic renal surgery.

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.

Laparoscopic retroperitoneal nephrectomy for Aspergillus-infected polycystic kidney.

BACKGROUND AND PURPOSE: The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. CASERESPORT: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection. CONCLUSION: The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

[Prognostic value of the localization of positive resection margins after radical prostatectomy for intraprostatic tumors]. / Intérêt pronostique de la localisation des marges d'exérèse positives après prostatectomie radicale pour les tumeurs intra-prostatiques.

OBJECTIVE: To evaluate the risk of biochemical recurrence of organ-confined prostate cancer (pT2+) after radical prostatectomy, according to the site of positive resection margins. MATERIAL AND METHODS: 649 radical prostatectomies were performed between 1988 and 2002 for organ-confined tumours in 436 cases (stage pT2). Preoperative (clinical stage, PSA assay and Gleason score on biopsies) and post-operative data (weight of the resection specimen, Gleason score and tumour volume) were recorded as a function of the site of positive resection margins. Biochemical recurrence was defined by a PSA level greater than 0.2 ng/ml. Biochemical progression-free survival was studied according to the Kaplan-Meier method, as a function of the site of positive resection margins. RESULTS: Sixty-six patients (15.1%) had a single positive margin. With a mean follow-up of 52.9 months (range: 1.1 to 160.4 months), eleven patients (16.6%) developed biochemical recurrence. The mean progression-free survival was 7.8 months. An apical positive resection margin was associated with the most unfavourable prognosis compared to other sites. CONCLUSION: Apical positive resection margins appear to be associated with a poorer prognosis than other sites. This study confirms that dissection of the apex is essential to ensure optimal tumour control and prognosis in organ-confined prostate cancer.

[Localization of positive surgical margins after retropubic, perineal and laparoscopic radical prostatectomy]. / Localisation des marges d'exérèse positives après prostatectomie radicale par voie rétropubienne, périnéale et laparoscopique.

OBJECTIVE: To study the sites of positive surgical margins after radical prostatectomy according to the technique used: retropubic, perineal or laparoscopic. MATERIAL AND METHODS: 538 radical prostatectomies were performed between 1988 and 2001: 184 via a retropubic approach, 119 via a perineal approach and 235 by laparoscopy. Clinical examination, PSA assay (Hybritech, Normal < 4 ng/ml) and transrectal biopsies were performed in all patients. The radical prostatectomy specimen was examined by the same pathologist according to the Stanford protocol. The frequency and site of positive surgical margins were studied as a function of pathological stage. RESULTS: The positive surgical margins rate was 32%, 18.5% and 26.4% for the retropubic, perineal and laparoscopic techniques, respectively. The most frequent site of positive surgical margins was the apex for retropubic (41.1%) and perineal (41.6%) prostatectomy and the posterolateral part of the prostate for laparoscopic prostatectomy (41.9%). The most frequent site of positive surgical margins in pT2 tumours was the apex for the retropubic approach (50%), the base of the prostate (bladder neck) for the perineal approach (41.6%) and the apex and posterolateral part of the prostate for the laparoscopic approach (44.4% and 41.6%). CONCLUSION: Each radical prostatectomy technique corresponds to a preferential site of positive surgical margins: the apex for the retropubic approach, the bladder neck for the perineal approach and the posterolateral part of the prostate for the laparoscopic approach.

[Simple nephrectomy with retroperitoneal laparoscopy]. / Néphrectomie simple par laparoscopie rétropéritonéale.

OBJECTIVE: Nephrectomy was one of the very first urological procedures to be performed by laparoscopy. The objective of this study was to evaluate the results of retroperitoneal laparoscopic simple nephrectomy. METHODS: From 1995 to 2002, 88 retroperitoneal laparoscopic simple nephrectomies were performed in 87 patients with a mean age of 45.3 years (range: 18 to 77 years). The intraoperative and postoperative complications, conversion rate, blood loss, operating time and length of hospital stay were studied for each patient. RESULTS: The mean operating time was 114 min (range: 35 to 280 min), mean blood loss was 97.6 ml (range: 0 to 300 ml), there were 3 conversions (3.4%) and the mean length of hospital stay was 4.7 days (range: 2 to 13 days). The main postoperative complications were 2 cases of haematoma and one abscess of the nephrectomy site requiring surgical revision and 3 intraoperative thromboses of arteriovenous fistulas in 3 patients with polycystic kidney disease. CONCLUSION: Due to its low morbidity, laparoscopic simple nephrectomy has probably become the, reference technique for all indications for nephrectomy for benign disease.

[How to present in a unique fashion the oncologic and functional results after radical prostatectomy]. / Comment présenter de façon unique les résultats carcinologiques et fonctionnels après prostatectomie radicale.

INTRODUCTION: The results of radical prostatectomy (cancer control, continence and sexual potency) are currently presented separately, while the success of this surgery depends on a combination of good cancer control with maintenance of continence and erections. We propose a score to jointly evaluate and report cancer control and functional results. METHODS: The results of 205 radical prostatectomies were studied at one year. Cancer control was evaluated by PSA and continence and sexual potency were evaluated by a self-administered questionnaire. Each patient was attributed 0 or 4 points according to the presence or absence of biochemical progression (PSA > 0.2 ng/ml), 0 or 2 points according to the presence or absence of urinary incontinence (use of pads) and 0 or 1 point according to the presence or absence of impotence (no erections). The sum of these points provided a socre classifying the patient into 8 distinct categories, from 0 to 7, each corresponding to a specific status (from 0 (0 + 0 + 0): no cancer control-incontinence-impotence to 7 (4 + 2 + 1): cancer control-continence-sexual potency). RESULTS: One year after the operation, 175 (85%) of patients had a PSA less than 0.2 ng/ml, 135 (65.8%) were continent and 64 (32.7%) reported erections. All patients with a score > or = 4 had good cancer control, wit no functional disorders for a score of 7 (4 + 2 + 1) (92%), no disorders of continence for a score of 6 (4 + 2 + 1) (31.5%), no disorders of erection for a score of 5 (4 + 0 + 1) (8.3%), or with incontinence and impotence for a score of 4 (4 + 0 + 0) (21.9%). All patients with a score < 4 had a PSA > 0.2 ng/ml, but with no functional disorders for a score for 3 (0 + 2 + 1) (2.4%), no incontinence for a score of 2 (0 + 2 + 0) (8.3%), and no impotence for a score of 1 (0 + 0 + 1) (1.9%). 1.9% of patients were incontinent, impotent and showed signs of biochemical progression (socre 0 = 0 + 0 + 0). CONCLUSION: This score allows analysis of the global (cancer control and functional) results of radical prostatectomy and would facilitate comparisons between various surgical techniques (type of approach, nerve-sparing techniques) and various centres.

EAU policy on live surgery events.

CONTEXT: Live surgery is an important part of surgical education, with an increase in the number of live surgery events (LSEs) at meetings despite controversy about their real educational value, risks to patient safety, and conflicts of interest. OBJECTIVE: To provide a European Association of Urology (EAU) policy on LSEs to regulate their organisation during urologic meetings. EVIDENCE ACQUISITION: The project was carried out in phases: a systematic literature review generating key questions, surveys sent to Live Surgery Panel members, and Internet- and panel-based consensus finding using the Delphi process to agree on and formulate a policy. EVIDENCE SYNTHESIS: The EAU will endorse LSEs, provided that the EAU Code of Conduct for live surgery and all organisational requirements are followed. Outcome data must be submitted to an EAU Web-based registry and complications reported using the revised Martin criteria. Regular audits will take place to evaluate compliance as well as the educational role of live surgery. CONCLUSIONS: This policy represents the consensus view of an expert panel established to advise the EAU. The EAU recognises the educational role of live surgery and endorses live case demonstration at urologic meetings that are conducted within a clearly defined regulatory framework. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery. PATIENT SUMMARY: Controversy exists regarding the true educational value of live surgical demonstrations on patients at surgical meetings. An EAU committee of experts developed a policy on how best to conduct live surgery at urologic meetings. The key principle is to ensure safety for every patient, including a code of conduct and checklist for live surgery, specific rules for how the surgery is organised and performed, and how each patient's results are reported to the EAU. For detailed information, please visit www.uroweb.org.

Initial prostate biopsy: development and internal validation of a biopsy-specific nomogram based on the prostate cancer antigen 3 assay.

BACKGROUND: Urinary prostate cancer antigen 3 (PCA3) assay in combination with established clinical risk factors improves the identification of men at risk of harboring prostate cancer (PCa) at initial biopsy (IBX). OBJECTIVE: To develop and validate internally the first IBX-specific PCA3-based nomogram that allows an individual assessment of a man's risk of harboring any PCa and high-grade PCa (HGPCa). DESIGN, SETTING, AND PARTICIPANTS: Clinical and biopsy data including urinary PCA3 score of 692 referred IBX men at risk of PCa were collected within two prospective multi-institutional studies. INTERVENTION: IBX (≥ 10 biopsy cores) with standard risk factor assessment including prebiopsy urinary PCA3 measurement. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PCA3 assay cut-off thresholds were investigated. Regression coefficients of logistic risk factor analyses were used to construct specific sets of PCA3-based nomograms to predict any PCa and HGPCa at IBX. Accuracy estimates for the presence of any PCa and HGPCa were quantified using area under the curve of the receiver operator characteristic analysis and compared with a clinical model. Bootstrap resamples were used for internal validation. Decision curve analyses quantified the clinical net benefit related to the novel PCA3-based IBX nomogram versus the clinical model. RESULTS AND LIMITATIONS: Any PCa and HGPCa were diagnosed in 46% (n=318) and 20% (n=137), respectively. Age, prostate-specific antigen, digital rectal examination, prostate volume, and PCA3 were independent predictors of PCa at IBX (all p<0.001). The PCA3-based IBX nomograms significantly outperformed the clinical models without PCA3 (all p<0.001). Accuracy was increased by 4.5-7.1% related to PCA3 inclusion. When applying nomogram-derived PCa probability thresholds ≤ 30%, only a few patients with HGPCa (≤ 2%) will be missed while avoiding up to 55% of unnecessary biopsies. External validation of the PCA3-based IBX-specific nomogram is warranted. CONCLUSIONS: The internally validated PCA3-based IBX-specific nomogram outperforms a clinical prediction model without PCA3 for the prediction of any PCa, leading to the avoidance of unnecessary biopsies while missing only a few cases of HGPCa. Our findings support the concepts of a combination of novel markers with established clinical risk factors and the superiority of decision tools that are specific to a clinical scenario.

Modified supine percutaneous nephrolithotomy for large kidney and ureteral stones: technique and results.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the standard treatment for kidney stones >2cm. Recently, a novel approach in the modified supine lithotomy position has been developed. OBJECTIVE: To demonstrate with a video our technique of supine PCNL (sPCNL) and present our experience. DESIGN, SETTING, AND PARTICIPANTS: From September 2009 to August 2010, 47 consecutive patients were prospectively evaluated. There were 31 single, 9 multiple, and 7 staghorn stones. The mean body mass index was 26.1±5 (range: 17.3-45.7), the mean stone size was 29.6±15.3mm (range: 10-75), and patients' American Society of Anesthesiologists scores were 1, 2, and 3 in 31, 11, and 5 cases, respectively. SURGICAL PROCEDURE: Patients were positioned in Galdakao-modified supine Valdivia position. The details of the technique are shown in the film. MEASUREMENTS: Success was defined as patients free of stones or with residual stone fragments <4mm. RESULTS AND LIMITATIONS: Average operative room occupation time was 123.5±51.2min (range: 50-245). In the single, multiple, and staghorn stone groups, the immediate success rate after sPCNL was 90%, 78%, and 43%, respectively. Complications included one fever, two incidents of pyelonephritis, one renal colic, two urinary fistulae, one postoperative hemorrhage, and one incident of acute urinary retention. Mean hospital stay was 3.4±1.9 d (range: 2-12). Nine patients (19%) had a secondary procedure (extracorporeal shock wave lithotripsy or flexible ureterorenoscopy). At 3 mo, the success rate was 97%, 100%, and 100% in the single, multiple, and staghorn stone groups, respectively. However, the limitation of this study is its design, which is descriptive rather than comparative. CONCLUSIONS: sPCNL is a safe and reproducible method. It offers the advantage of simultaneous retrograde and antegrade endoscopic combined intrarenal surgery, and we believe it is a further advancement in stone management. In addition, it is easier from the anesthetist point of view than the traditional prone approach. In our hands, it meant a simplification of the operative technique, resulting in a more time-efficient procedure.

Laparoscopic partial nephrectomy: is it worth still performing the retroperitoneal route?

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190 ± 85 min versus 154 ± 47 (P = 0.001) and 9.2 ± 6.4 days versus 6.2 ± 4.5 days (P < 0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (P = 0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (P = 0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.

Fluoroscopy-guided renal access in supine percutaneous nephrolithotomy.

OBJECTIVE: To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). PATIENTS AND METHODS: From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. RESULTS: Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35-180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. CONCLUSIONS: This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.

Robot-assisted laparoscopic sacral colpopexy: initial experience in a high-volume laparoscopic reference center.

PURPOSE: To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center. PATIENT AND METHODS: 12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence. RESULTS: Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred. CONCLUSION: RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.

Intrafascial nerve-sparing radical prostatectomy with a laparoscopic robot-assisted extraperitoneal approach: early oncological and functional results.

OBJECTIVE: We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. METHODS: From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. RESULTS: The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. CONCLUSIONS: An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.