Significance of prostate weight on peri and postoperative outcomes of robot assisted laparoscopic extraperitoneal radical prostatectomy.

INTRODUCTION: To determine the significance of prostate weight (PW) on clinical and pathological outcomes in patients undergoing da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP). METHODS: From November 2008 to January 2010, 295 men underwent EP-RARP at our institution. We retrospectively reviewed our database and stratified patients into four groups based on pathologic PW: Group 1, less than 30 g; Group 2, 30 g to less than 50 g; Group 3, 50 g to less than 80 g; and Group 4, 80 g or larger. We prospectively compared these groups with respect to patient age, body mass index, prostate-specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate and length of stay. Statistical analysis was performed using SYSTAT 13 software. An analysis of variance (ANOVA) model was used to compare the continuous variables among the groups. Chi-square and Fisher's exact tests were used to compare categorical variables. RESULTS: Of the 295 patients, 10, 182, 91, and 12 had a PW of less than 30 g; 30 g to less than 50 g; 50 g to less than 80 g; and 80 g or larger, respectively. A significant difference was found in age, prostate weight and prostate-specific antigen values among the four groups (p < 0.05). Patients in Group 4 had larger prostates, were older (mean age 65 years), had higher pretreatment prostate-specific antigen (median 5.85 ng/mL) and lower Gleason score (mean 6.2). Based on the D'Amico risk stratification, our study showed a trend toward higher risk disease, presence of extra capsular extension, seminal vesicle invasion and positive margin status in Groups 1, 2 and 3 rather than in Group 4. No significant differences in operative time, estimated blood loss, transfusion rate, hospital stay, and postoperative complication rate were observed among the four groups. CONCLUSIONS: Da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP) is feasible in patients with larger prostates, offering acceptable operative times, blood loss, hospital stay and complication rates. In our cohort of patients, we found pathologically smaller prostates are generally associated with higher Gleason score, higher risk group stratification and positive surgical margin status. Although technically challenging, increased prostate weight should not be considered a contraindication for EP-RARP if performed by experienced surgeons.

Assessment of critical renal ischemia with real-time infrared imaging.

BACKGROUND: Currently visual and tactile clues such as color, mottling, and tissue turgor are used in the operating room for subjective assessments of organ ischemia. Studies have demonstrated that infrared (IR) imaging is a reliable tool to identify perfusion of brain tumors and kidneys during human surgery. Intraoperative IR imaging has the potential for more objective real-time detection and quantitative assessment of organ viability including early ischemia. We hypothesize, by detecting variations of the IR signal, we can assess the degree to which renal surface temperature reflects underlying renal ischemia. To address this hypothesis, IR imaging-derived temperature fluctuations were evaluated during laparotomy in a porcine model (n = 15). These temperature profiles then underwent spectral (frequency) analysis to assess their relationship to well-described oscillations of the microcirculation. MATERIALS AND METHODS: An IR camera was positioned 30-60 cm above the exposed kidneys. Images (3-5 mum wavelength) were collected (1.0/s) at baseline, during warm renal ischemia, and during reperfusion. Dominant frequency (DF) of the tissue temperature fluctuations were determined by a Fourier transformation (spectral) analysis. RESULTS: IR images immediately showed which segments of the kidney were ischemic. DF at approximately 0.008 Hz that corresponds to blood flow oscillations was observed in thermal profiles. The oscillations were diminished or disappeared after 25 min of warm ischemia and were recovered with reperfusion in a time-dependent fashion. Oscillations were attenuated substantially in ischemic segments, but not in perfused segments of the kidney. CONCLUSIONS: The described oscillations can be measured noninvasively using IR imaging in the operating room, as represented by the DF, and may be an early marker of critical renal ischemia.

Treatment of bladder cancer in cardiac transplant patients.

We report a patient who presented with superficial bladder tumors 8 years after cardiac transplantation. He was managed conservatively with intra-vesical therapy for 5 years and ultimately underwent a successful radical cystoprostatectomy and urethrectomy 13 years after cardiac transplantation. This illustrates that cardiac transplant patients with superficial tumors may be managed with conservative therapies, but close vigilance is necessary to identify the opportune time for extirpative surgery.

Evaluation of a minimally invasive renal cooling device using heat transfer analysis and an in vivo porcine model.

Partial nephrectomy is the gold standard treatment for renal cell carcinoma. This procedure requires temporary occlusion of the renal artery, which can cause irreversible damage due to warm ischemia after 30 min. Open surgical procedures use crushed ice to induce a mild hypothermia of 20°C in the kidney, which can increase allowable ischemia time up to 2.5 h. The Kidney Cooler device was developed previously by the authors to achieve renal cooling using a minimally invasive approach. In the present study an analytical model of kidney cooling in situ was developed using heat transfer equations to determine the effect of kidney thickness on cooling time. In vivo porcine testing was conducted to evaluate the cooling performance of this device and to identify opportunities for improved surgical handling. Renal temperature was measured continuously at 6 points using probes placed orthogonally to each other within the kidney. Results showed that the device can cool the core of the kidney to 20°C in 10-20 min. Design enhancements were made based on surgeon feedback; it was determined that the addition of an insulating air layer below the device increased difficulty of positioning the device around the kidney and did not significantly enhance cooling performance. The Kidney Cooler has been shown to effectively induce mild renal hypothermia of 20°C in an in vivo porcine model.

Successful outpatient management of the nonpalpable intra-abdominal testis with staged Fowler-Stephens orchiopexy.

PURPOSE: Previous reports of orchiopexies have shown an 85.9% success rate for staged Fowler-Stephens orchiopexy (FSO). We review our experience with nonpalpable testes (NPTs). MATERIALS AND METHODS: A total of 119 patients with 128 NPTs were treated at our institution between 1994 and 2001. Atrophic testes or "nubbins" were removed. Once an intra-abdominal testis was identified the peritoneum was opened and firm traction was placed on the gonad. If feasible, primary orchiopexy was completed. Otherwise, staged Fowler-Stephens orchiopexy was performed. RESULTS: Primary orchiopexy was performed in 28 testes in 27 patients without division of the spermatic vessels. An atrophic nubbin was removed in 45 patients. All children with bilateral NPTs had at least 1 viable intra-abdominal testis found at surgery. Staged FSO was performed in 55 testes in 47 children. The second stage was performed at a median of 3.5 months after initial ligation of the spermatic vessels. Median followup was 1 year and mean followup was 9 months. Five patients were lost to followup. Successful surgery was defined as a dependent scrotal location and testis size equivalent to the contralateral mate. The overall success rate for the primary orchiopexy group was 100%. In the staged FSO group 1 patient had an atrophic testis at 1-year followup, yielding an overall success rate of 98%. CONCLUSIONS: A high degree of success can be obtained for children with intra-abdominal testes. Mobility of the testis on exploration is a good indicator that the testis can be managed with primary orchiopexy without division of the vessels. If primary orchiopexy cannot be performed, excellent results are achieved with a staged FSO.