Effect of metastatic site on emergency department disposition in men with metastatic prostate cancer.

INTRODUCTION: Though the prevalence of metastatic prostate cancer is decreasing, the rate of admission from the emergency department (ED) is increasing. Little is known about the implications of metastatic site on a patient's ED course and admission. MATERIALS AND METHODS: A weighted estimate of 15,367 patients with metastatic prostate cancer who presented to the ED between January 1, 2006 and December 31, 2009 was abstracted from the Nationwide Emergency Department Sample (NEDS). Descriptive statistics were used to elaborate patient and hospital characteristics of the metastatic prostate cancer population and logistic regression models were fitted to identify predictors of admission. RESULTS: The most common site of metastasis in patients with metastatic prostate cancer presenting to the ED was bone (80.6%), followed by liver (13.2%), lung (9.3) and other genitourinary sites (8.1%). Over the study period, there was an increase in prevalence of the four commonest metastatic sites, and admission rates varied between metastatic sites (83.2% for bone to 95.2% for nodal metastasis). Substantial variability in the rate of inpatient mortality was noted. Increasing age, Northeast region, increased comorbidity burden, and the presence of nodal metastases and other urinary metastases were shown to be independent predictors of hospital admission. CONCLUSIONS: The commonest metastatic site in patients presenting to United States EDs with metastatic prostate cancer between 2006 and 2009 was bone. Patients presenting with nodal metastases were most likely to be admitted. Independent predictors of hospitalization included age, Northeast region, increased comorbidities, nodal metastases and other urinary metastases.

Robotic ultrasound probe for tumor identification in robotic partial nephrectomy: Initial series and outcomes.

OBJECTIVES: Accurate tumor identification during partial nephrectomy is essential for successful tumor control. Intraoperative laparoscopic ultrasonography is useful for tumor localization, but the ultrasound probe is controlled by the assistant rather than the surgeon. We evaluated our initial experience using a robotic ultrasound probe that is controlled by the console surgeon. METHODS: Partial nephrectomy was carried out in 22 consecutive patients between November 2010 and March 2011. A robotic ultrasound probe under console surgeon control was used in all the cases. All patients had at least 1 year follow up. RESULTS: Mean patient age was 59 years and mean tumor size was 2.7 cm. There were six hilar tumors (27%) and 21 (95%) endophytic tumors. Mean R.E.N.A.L. nephrometry score was 6.9 (range 6-9). Mean operative time was 205.7 min and mean warm ischemia time was 17.9 min (range 6-28 min). All patients had negative tumor margins and were free of disease recurrence at a mean follow up of 13 months. CONCLUSION: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure.

Tumor complexity predicts malignant disease for small renal masses.

PURPOSE: Approximately 20% to 30% of suspicious small renal tumors are benign. A significant proportion of malignant tumors are low grade and potentially indolent. We evaluated whether preoperative patient and tumor characteristics are associated with adverse pathological features. MATERIALS AND METHODS: A total of 886 patients underwent robot-assisted partial nephrectomy, as done by 1 of 5 high volume surgeons. Demographic and clinical data were compared between patients with benign/malignant disease, clear cell/nonclear cell renal cell carcinoma and high/low grade tumors. Tumor complexity was quantified by R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar and location relative to polar lines) nephrometry score and described as low--4 to 6, intermediate--7 to 9 or high--10 or greater. Logistic regression analyses were performed to test the association between tumor and patient characteristics, and high grade renal cell carcinoma. Subanalyses were done for patients with renal tumors 4 cm or less. RESULTS: High grade renal cell carcinoma was larger and more likely to develop in men. Patients with malignant tumors and with clear cell histology were more likely to have intermediate or high complexity tumors. Increasing tumor complexity independently predicted malignancy, high grade malignancy and clear cell histology on multivariate regression analysis (each p <0.05). Male gender was independently associated with malignancy and high grade renal cell carcinoma. When considering tumors 4 cm or less, tumor complexity predicted malignancy but not tumor grade. CONCLUSIONS: High R.E.N.A.L nephrometry score and male gender are associated with an increased risk of malignancy and high grade malignancy in tumors treated with partial nephrectomy.

Sodium butyrate and short chain fatty acids in prevention of travellers' diarrhoea: a randomized prospective study.

INTRODUCTION: Travellers' diarrhoea (TD) remains a considerable concern among international travellers. Known methods of prevention include dietary precautions, administration of vaccines and antibiotic agents. AIM: To assess the efficacy of sodium butyrate (SB) and short-chain fatty acids (SCFA) in prevention of TD. MATERIAL AND METHODS: 67 adult patients planning to travel to subtropical countries were originally enrolled in the study. After eliminating 7 patients for not fulfilling the inclusion criteria, 60 patients were randomized into a study group receiving SB with SCFA and a placebo group. Patients were requested to complete previously distributed questionnaire daily. After elimination of 18 patients who did not return questionnaires, 42 patients completed the study (22 study, 20 placebo). RESULTS: In comparison to the control arm, the study arm noted significantly reduced occurrence of TD (4.5% vs. 40%, p = 0.008), was associated with a significant decrease in number of stools per day in travellers (1.9 vs. 4.2, p = 0.04), as well as a decrease in gastrointestinal symptoms including pain, bloating and nausea with fevers (0.7 vs. 1.4, p = 0.01). We recorded a trend towards decrease in diarrhoea related utilization of medical care in subjects from the study arm. There were no adverse effects noted regarding the use of SB and SCFA. CONCLUSIONS: Administration of SB with SCFA decreases occurrence of travellers' diarrhoea. It is safe and may constitute a new method of travellers' diarrhoea prevention.

Robot-assisted partial nephrectomy in patients with baseline chronic kidney disease: a multi-institutional propensity score-matched analysis.

BACKGROUND: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. OBJECTIVE: To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD. DESIGN, SETTING, AND PARTICIPANTS: A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60 ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR ≥60 ml/min per 1.73 m(2)). INTERVENTION: RPN in patients with or without baseline CKD. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score-matched operative and functional outcomes. RESULTS AND LIMITATIONS: After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study. CONCLUSIONS: RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.

Comparison of robotic and laparoscopic ultrasound probes for robotic partial nephrectomy.

OBJECTIVES: To evaluate and compare perioperative outcomes of robotic partial nephrectomy (RPN) using robotic and laparoscopic ultrasound probe for tumor identification. MATERIALS AND METHODS: Data from 75 consecutive RPN procedures using a laparoscopic ultrasound probe (January 2009- November 2010) and 75 consecutive RPN procedures using a robotic ultrasound probe (November 2010- November 2011) were collected. Perioperative outcomes of the two groups were retrospectively analyzed. RESULTS: A total of 72 patients underwent 75 consecutive RPN using the laparoscopic ultrasound probe followed by 73 patients who underwent 75 consecutive RPNs using the robotic ultrasound probe. Characteristics were similar between groups, and tumors had a similar complexity (mean nephrometry score 6.6 vs. 6.8, p=0.534), mean operating room time (234 vs. 218 min, p=0.095), mean console time (173 vs. 156 min, p=0.071), mean blood loss (171 mL vs. 164 mL, p=0.79), and positive tumor margin rates (1.2% vs. 2.2%, p=1) did not achieve significance. All patients are free of cancer recurrence after a mean follow up of 25.7 months in the laparoscopic probe group and of 10.2 months in the robotic probe group. CONCLUSIONS: Robotic ultrasound probes for tumor identification during RPN had comparable perioperative outcomes and surgical margin rates as a laparoscopic ultrasound probe, but with the advantage of surgeon autonomy.

Robotic partial nephrectomy for solitary kidney: a multi-institutional analysis.

OBJECTIVE: To evaluate the outcomes of robotic partial nephrectomy (RPN) for solitary kidney in a large multicenter series. MATERIALS AND METHODS: Medical records of 886 consecutive patients who underwent RPN at 5 academic institutions from May 2007 to May 2012 were retrospectively analyzed. Data were prospectively collected in an Investigational Review Board-approved protocol. Experienced robotic surgeons performed all operations. Patient demographics, functional, perioperative, and early oncologic outcomes were analyzed. RESULTS: A total of 26 patients with a solitary kidney were identified and included in the analysis; of these, 16 (62%) had solitary kidneys secondary to a previous malignancy. Perioperative outcomes included a median warm ischemia time of 17 minutes (interquartile range, 12, 28 minutes). Only 2 intraoperative complications occurred. One was a renal vein injury and one an aortic vessel tear, and both patients required intraoperative blood transfusions. No conversions to laparoscopy or open surgery occurred. There were 3 postoperative complications (11.5%). Median follow-up was 6 months (interquartile range, 5, 9.7 months). Postoperative renal function did not change significantly as measure by estimated glomerular filtration rate (-15.8%; P=.13). None of the patients required dialysis. Positive margins occurred in 1 patient, with 73% of patients having a renal cell carcinoma. CONCLUSION: We report a multi-institutional series of RPN in patients with solitary kidney presenting with small renal masses. Our findings suggest that RPN represents a feasible treatment option in this specific population by offering reliable preservation of renal function, low surgical morbidity, and early oncologic safety in the hands of experienced robotic surgeons.

Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers.

OBJECTIVE: To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system. MATERIALS AND METHODS: A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade. RESULTS: Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates. CONCLUSION: Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively.

Off-clamp robot-assisted partial nephrectomy preserves renal function: a multi-institutional propensity score analysis.

BACKGROUND: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking. OBJECTIVE: To evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls. INTERVENTION: RPN without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score matching. RESULTS AND LIMITATIONS: Patients undergoing off-clamp RPN had a mean tumor size of 2.5 cm (standard deviation [SD]: ± 2.1) and a mean RENAL nephrometry score of 5.3 (SD: ± 1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ± 29). The mean estimated blood loss (EBL) was 210 ml (SD: ± 212), and the mean operative time was 155 min (SD: ± 46). No Clavien 3-5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1-3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156 min compared with 185 min, p<0.001), a higher EBL (228 ml compared with 157 ml, p=0.009), and a smaller decrease in eGFR (2% compared with -6%, p=0.008). The retrospective analysis was the main limitation of this study. CONCLUSIONS: With appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function.

Tablet telerounding.

OBJECTIVE: To evaluate the feasibility of remote rounding using commercially available standard tablets with videoconferencing system and assess patient satisfaction. METHODS: Thirty-two patients with at least 2 postoperative days of hospital stay after robotic urologic procedures were included in the study. On the first postoperative day, the physician-patient encounter was performed as telerounding with videoconferencing due to the physician's duties scheduled in another affiliated hospital. On the second day, the personal bedside encounter took place. The tablet we used was an iPad2 (Apple, iOS 5.1; Apple, Cupertino, CA) with a videoconferencing application. A telerounding satisfaction survey was fulfilled by all patients on the touchscreen of the tablet. RESULTS: Average time of telerounding encounter was 4.5 minutes (range, 1.0-13.5 minutes), average age of the patient was 57.7 years (range, 19-80 years), and 19 were men (59%). Patients expressed a high level of satisfaction with 91% of patients stating that their care was better using telerounding and 97% of patients stating that telerounding should be a regular part of patient care in the hospital. Additionally, 94% of patients stated that they could easily communicate with their doctor over the telerounding system, 84% of patients agreed that they would feel comfortable with telerounding daily if they were hospitalized again and 81% of patients would prefer telerounding communication with their doctor than be directly seen by another doctor. CONCLUSION: Tablet telerounding using videoconferencing can be a strong supplementing tool in doctor-patient communication. It is convenient for the physician and increases the patient's hospital stay satisfaction.

Live robotic surgery: are outcomes compromised?

OBJECTIVE: To determine the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast surgery compared to a cohort treated without observers. METHODS: From 2007 to 2011, 39 robotic partial nephrectomies were performed as live broadcast surgery by 1 of 5 high volume surgeons. Live broadcast cases were defined as surgeries viewed by multiple visiting physicians via live teleconference in which the visitors were able to interact with the operating surgeon. Live cases were compared with 847 cases performed under standard operating procedure during the same period. Cases performed under standard operating procedure were not broadcasted. Demographic, clinicopathologic, and perioperative outcomes were compared between groups. Logistic regression analysis was performed to the test the association between live broadcast surgery and adverse perioperative outcomes. RESULTS: Demographic and clinicopathologic data were similar between both groups. The live broadcast surgery group experienced equivalent operative times (196.3 vs 183.8 minutes; P = .22), estimated blood loss (EBL; 187.8 vs 190.7; P = .93), warm ischemia time (WIT; 20.8 vs 18.8; P = .17), hospital length of stay (LOS; 2.8 vs 2.8 days; P = .99), positive surgical margin rate (2.6% vs 2.3%; P = .83), and rates of postoperative complications (5.1% vs 12.8%; P = .16). There were no Clavien III to V complications in the live broadcast group. Logistic regression analyses demonstrated that live broadcast surgery was not associated with any unfavorable perioperative parameter. CONCLUSION: Live robotic surgery is associated with excellent patient outcomes which compare favorably to cases done under normal operating procedures. Live robotic surgery represents a powerful educational tool which may be used without increasing patient morbidity.