Efficacy of robot-assisted radical cystectomy (RARC) in advanced bladder cancer: results from the International Radical Cystectomy Consortium (IRCC).

OBJECTIVE: To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer. PATIENTS AND METHODS: Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality. RESULTS: In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3-5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality. CONCLUSIONS: RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients.

International Robotic Radical Cystectomy Consortium: A way forward.

Robot-assisted radical cystectomy (RARC) is an emerging operative alternative to open surgery for the management of invasive bladder cancer. Studies from single institutions provide limited data due to the small number of patients. In order to better understand the related outcomes, a world-wide consortium was established in 2006 of patients undergoing RARC, called the International Robotic Cystectomy Consortium (IRCC). Thus far, the IRCC has reported its findings on various areas of operative interest and continues to expand its capacity to include other operative modalities and transform it into the International Radical Cystectomy Consortium. This article summarizes the findings of the IRCC and highlights the future direction of the consortium.

Impact of surgeon and volume on extended lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium (IRCC).

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Lymph node dissection and it's extend during robot-assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot-assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings. OBJECTIVE: To evaluate the incidence of, and predictors for, extended lymph node dissection (LND) in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer, as extended LND is critical for the treatment of bladder cancer but the role of minimally invasive surgery for extended LND has not been well-defined in a multi-institutional setting. PATIENTS AND METHODS: Used the International Robotic Cystectomy Consortium (IRCC) database. In all, 765 patients who underwent RARC at 17 institutions from 2003 to 2010 were evaluated for receipt of extended LND. Patients were stratified by age, sex, clinical stage, institutional volume, sequential case number, and surgeon volume. Logistic regression analyses were used to correlate variables to the likelihood of undergoing extended LND. RESULTS: In all, 445 (58%) patients underwent extended LND. Among all patients, a median (range) of 18 (0-74) LNs were examined. High-volume institutions (≥100 cases) had a higher mean LN yield (23 vs 15, P < 0.001). On univariable analysis, surgeon volume, institutional volume, and sequential case number were associated with likelihood of undergoing extended LND. On multivariable analysis, surgeon volume [odds ratio (OR) 3.46, 95% confidence interval (CI) 2.37-5.06, P < 0.001] and institution volume [OR 2.65, 95% CI 1.47-4.78, P = 0.001) were associated with undergoing extended LND. CONCLUSIONS: Robot-assisted LND can achieve similar LN yields to those of open LND after RC. High-volume surgeons are more likely to perform extended LND, reflecting a correlation between their growing experience and increased comfort with advanced vascular dissection.

The distribution of patients who seek treatment for the complaint of ejaculating prematurely according to the four premature ejaculation syndromes.

INTRODUCTION: In addition to "lifelong" and "acquired" premature ejaculation (PE) syndromes, two more PE syndromes have recently been proposed: "Natural variable PE" and "premature-like ejaculatory dysfunction." AIM: The purpose of this study was to analyze the prevalence of the four PE syndromes among patients who were admitted to a urology outpatient clinic with the complaint of ejaculating prematurely. METHODS: Between July 2008 and March 2009, patients admitted to a urology outpatient clinic with a self-reported complaint of PE were enrolled into the study. After taking a careful medical and sexual history, patients were classified as "lifelong,""acquired,""natural variable," PE or "premature-like ejaculatory dysfunction." MAIN OUTCOME MEASURES: In addition to medical and sexual history, self-estimated intravaginal ejaculatory latency times (IELTs) of patients were used in the classification of patients. RESULTS: A total of 261 potent men with a mean age of 36.39 +/- 10.45 years (range 20-70) were recruited into the study. The majority of the men was diagnosed as having lifelong PE (62.5%); the remaining men were diagnosed as having acquired (16.1%), natural variable PE (14.5%), or premature-like ejaculatory disorder (6.9%). The mean age of patients with acquired PE was significantly higher than the other groups (P = 0.001). No significant difference was observed for educational status or income level of patients in the different PE groups (P = 0.983 and P = 0.151, respectively). The mean self-estimated IELT for all subjects was 65.16 +/- 83.75 seconds (2-420 seconds). Patients with lifelong PE had significantly lower mean self-reported IELT, whereas the patients with premature-like ejaculatory dysfunction had the highest mean IELT (P = 0.001): (i) life-long PE: 20.47 +/- 28.90 seconds (2-120 seconds); (ii) aquired PE: 57.91 +/- 38.72 seconds (90-180 seconds); (iii) natural variable PE: 144.17 +/- 22.47 seconds (120-180 seconds); and (iv) premature-like ejaculatory dysfunction: 286.67 +/- 69.96 seconds (180-420 seconds). CONCLUSIONS: The majority of patients who seek treatment for the complaint of ejaculating prematurely describes lifelong PE. Further population-based studies are required to determine the actual prevalences of these four PE syndromes.

Testis sparing surgery for sequential bilateral testicular tumors.

OBJECTIVE: We present our experience in performing testis sparing surgery (TSS) to treat sequential bilateral testicular tumors. MATERIAL AND METHODS: We performed TSS on two patients with bilateral sequential testicular tumors. RESULTS: A 43-year-old patient (Case 1) and a 33-year-old patient (Case 2) had previous inguinal orchiectomy for seminoma. The patients were diagnosed with secondary testicular tumors in the contralateral testes on follow up. They were treated with TSS after frozen section analysis of the peritumoral testicular tissue. Pathologic evaluation of the removed tumors revealed immature teratoma and Leydig cell tumor. Both patients are disease free without local recurrence and do not have erectile dysfunction, and thus do not need androgen replacement therapy after a follow up of 6 months and 44 months, respectively. CONCLUSIONS: TSS after frozen section analysis appears to be a safe and feasible procedure that, in carefully selected cases, offers adequate cancer control, preserves sexual function, and provides psychological benefits.

Preoperative and postoperative seminal nitric oxide levels in patients with infertile varicocele.

In vitro studies have shown that nitric oxide (NO), inhibits sperm motility at high concentrations. In this study we aimed to determine the NO levels in the seminal fluid of patients with infertile varicocele both pre and postoperatively and in the control group, and compare the results. 20 men with varicocele presented to our clinic for primary infertility and 15 normal fertile men as controls were involved to study. NO levels in the seminal fluid were determined as the total nitrite by Griess reaction and results were compared with Mann-Whitney U test. Preoperative and postoperative mean seminal fluid NO levels in patients with varicocele were 114.82 +/- 33.02 micromol/L and 93.17 +/- 27.24 micromol/L, respectively. In the control group it was 89.4 +/- 20.82 micromol/L. There was a statistically significant different between mean preoperative and postoperative seminal NO levels (p < 0.05), whereas there was no significant difference between mean postoperative seminal NO levels and that of control group (p > 0.05). According to the results of present study, an increase in the level of seminal NO levels may play a role in the sperm dysfunction in infertile patients with varicocele.

Bacterial translocation to kidney in rats with intestinal obstruction and the role of nitric oxide.

OBJECTIVE: Bacterial translocation (BT) is the passage of viable indigenous bacteria from one site to another, such as from gastrointestinal tract to the normally sterile regional mesenteric lymph nodes and than other internal organs. In this study we aimed to investigate the BT to kidney and the protective effect of nitric oxide (NO) inhibition. MATERIAL AND METHODS: A total of 40 adult male Wistar albino rats weighing 320-350g were divided into four equal groups. Group 1 (n = 10): control group, group-2 (n = 10) sham control, group-3 (n = 10) simple obstruction, in which ileum was ligated 1-2 cm proximal to the ileocecal valve, group-4 (n = 10), simple obstruction and treated with L-NAME. Twenty four hour after the operation rats were sacrificed and kidneys were removed by sterile manner and trunk blood obtained for NO analysis. BT was defined as any positive culture from the blood and kidney. Results were compared with Mann- Whitney U test. RESULTS: NO levels in control, sham group, simple obstruction group and obstruction plus L-NAME treated group were 14.04 +/- 0.65 micromol/L, 13.03 +/- 0.080 micromol/L, 31.17 +/- 0.40 micromol/L and 12.24 +/- 0.70 micromol/L, respectively. Renal culture results were negative in all controls and sham operated rats. However, all culture results were positive in obstruction group and in 4 in L-NAME-treated group. The most common microorganism that translocated was E. coli. CONCLUSION: This experimental study shows that BT to rat rat kidneys occurs in bowel obstruction and this can be inhibited by a NO inhibitor, L-NAME. Further studies are needed to define the clinical significance of these findings on urinary tract infection.

Routine postoperative chest radiography is not needed after flank incisions with eleventh rib resection.

INTRODUCTION: We wanted to determine whether routine postoperative chest radiography is needed after surgery with eleventh rib resection. MATERIALS AND METHODS: Data on 80 patients who underwent radical or partial nephrectomy, nephroureterectomy or adrenalectomy through 82 flank incisions with eleventh rib resection were collected and analyzed retrospectively. RESULTS: Radical and partial nephrectomies, nephroureterectomies and adrenalectomies were done through 47, 20, 6 and 9 flank incisions in 80 patients, respectively. Among these, one patient underwent a partial nephrectomy and subsequent contralateral radical nephrectomy, and another patient underwent simultaneous bilateral adrenalectomies. The intrapleural space was entered accidentally in 16 flank incisions (19.51%). Repair was performed with a simple evacuation technique at the time of surgery, and a chest tube was needed in only three patients (18.75%) according to postoperative chest x-ray evaluation after pleural repair. Of the remaining patients who had no evidence of pleural opening on the water seal test before wound closure, none developed respiratory distress postoperatively and no chest x-rays were ordered, except for one patient who developed subcutaneous emphysema on the day of surgery where no evidence of pneumothorax was detected. CONCLUSIONS: We concluded that when pleural injury was not observed and confirmed via the water seal test, none of the patients developed respiratory distress, and this suggests that there is no need to check for its presence with chest x-ray postoperatively.

Comparison of antioxidant enzyme activity in the internal spermatic vein and brachial veins of patients with infertile varicocele.

AIM: Recent studies have shown that both oxidative and reductive stresses are present within the internal spermatic vein of patients with varicocele. The aim of this study was to compare the activities of antioxidant enzymes in the internal spermatic vein and brachial vein of patients with varicocele. METHODS: Fifteen primary infertile varicocele patients and ten normal-nonvaricocele-fertile control subjects participated in this study. The patients and subjects were first given a physical and color doppler examination, and then whole blood samples were drawn from the brachial vein and a dilated internal spermatic vein during surgery. Superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) enzyme activities were assessed by enzymatic methods, and the results were compared using the Mann-Whitney U test. RESULTS: The activity of SOD in the internal spermatic veins and brachial veins of patients with varicocele was 60.17+/-2.15 and 42.10+/-1.60 U/g protein, respectively; that of GSH-Px was 5.44+/-0.14 and 3.92+/-0.14 U/g protein, respectively. The results were statistically significant (P<0.05). In the control group, the activity of SOD in the internal spermatic veins and brachial veins was 43.12+/-1.80 and 40.01+/-2.10 U/g protein, respectively; that of GSH-Px was 3.35+/-0.20 and 3.7+/-0.10 U/g protein, respectively (P>0.05). CONCLUSIONS: Increased antioxidant enzyme activity in the internal spermatic vein may be due to increased oxidative stress in the internal spermatic vein: the increase in antioxidant enzyme activity may be a response to offset the toxic actions of reactive oxygen species. Further studies are needed to confirm this suggestion.

Standard percutaneous nephrolithotomy on a pelvic kidney without any ancillary modalities.

We are presenting a patient with two calculi in a right pelvic kidney managed by percutaneous nephrolithotomy with an access just above the iliac crest in the prone position.

RIRS is equally efficient in patients with different BMI scores.

The objective of the study was to ascertain whether flexible ureteroscopy with holmium laser lithotripsy and/or extraction of stone fragments is as effective in obese patients as in non-obese patients. The patients were divided into four groups (group 1: normal weight = 79 procedures, group 2: overweight = 123 procedures, group 3: obese = 87 procedures, and group 4: morbidly obese = 20 procedures) according to BMI cohorts. Patient charts were retrospectively reviewed and relevant data collected. A total of 309 operations were included in the present study. The overall mean ± SD (range) age was 41 ± 12 years (18-82), BMI 29 ± 6 kg/m(2) (18-52), operative time 64 ± 29 min (20-200), hospital stay 25 ± 11 h (4-168), stone number 3 ± 2 (1-15), stone burden 21 ± 14 mm (4-98), and internal stenting time 26 ± 8 days (2-60). Mean stone size was 10 ± 6, 9 ± 5, 11 ± 8, and 11 ± 8 mm for groups 1 through 4, respectively. There were no differences among groups regarding patients and stone characteristics, and perioperative parameters including patient age, operative time, hospital stay, and complications. Overall SFRs were similar between groups (81, 87, 87.4, and 85%, respectively; χ(2)=3.304, p=0.770) as were the complication rates (12-16%). Our contemporary Retrograde Intrarenal Surgery (RIRS) series showed that operative times, hospital stays, ancillary equipment use (internal stent, basket, etc.), SFRs, and complication rates were independent of BMI. Therefore, RIRS can be performed as efficiently and efficaciously in obese patients as in non-obese patients.

Comparison of clinical outcome of extracorporeal shockwave lithotripsy in patients with radiopaque v radiolucent ureteral calculi.

PURPOSE: To compare the efficacy of extracorporeal shockwave lithotripsy (SWL) in patients with radiopaque and radiolucent ureteral calculi. PATIENTS AND METHODS: Between September 2001 and August 2002, a total of 113 consecutive patients with ureteral calculi (58 radiopaque [Group 1], 55 radiolucent [Group 2]) were treated with a Multimed 2001 trade mark lithotripter under fluoroscopic monitoring. Localization of radiolucent stones was achieved after a bolus injection of contrast medium 1 mL/kg, the shockwaves being focused just below the end of contrast column. All patients were treated on an outpatient basis under analgesia and light sedation if required. The mean follow-up was 14 (range 6-23) months. Patients were reevaluated by some combination of plain films, ultrasound scanning, and intravenous urography 3 months after the treatment. Groups were compared with ANOVA and Mann-Whitney U tests. A P value <0.05 was regarded as statistically significant. RESULTS: There were no statistically significant differences in any parameter between groups. At 3 months, the success rate (stone-free status) was 87.9% in Group 1 and 89% in Group 2 (P = 0.848). Double-J catheter replacement was needed for three patients in Group 1 and for two patients in Group 2 (P = 0.693). Two patients from Group 1 and three from Group 2 underwent intracorporeal lithotripsy with ureterorenoscopy (P = 0.606). No adverse reactions to contrast medium occurred in Group 2. CONCLUSION: Patients with radiolucent ureteral calculi can be treated efficiently with SWL by contrast medium injection if ultrasonic localization is not possible.

Routine ureteral dilatation is not necessary for ureteroscopy.

PURPOSE: To present our experience in ureteroscopic lithotripsy and stone extraction without ureteral dilatation. PATIENTS AND METHODS: A total of 134 consecutive patients (80 male and 54 female), with a mean age of 36.4 (18-65) years underwent ureteroscopic stone removal. The stones were located in the lower, middle, and upper parts of the ureter in 92, 18 and 24 patients and the mean stone diameters were 9.2 (6-15) mm, 10.5 (8-15) mm and 8.8 (8-10) mm, respectively. A semirigid ureteroscope 8 F in size was used without any ureteral dilatation. The stones were fragmented by a pneumatic lithotripter in the ureter and the fragments were removed by a basket catheter or stone forceps. All patients were re-evaluated with a plain film on postoperative first day and with intravenous urography (IVU) at 3 months. Residual fragments bigger than 3 mm were accepted as treatment failure. RESULTS: The mean operation time was 44 (20-120) minutes. After the operation, the stone-free rate was 89/92 (97%) for lower, 15/18 (83%) middle and 18/24 (75%) upper ureteral stones, respectively. Double J catheter replacement was needed in 13 patients due to impacted stone and/or failed procedure. Ureteral perforation did not occur in any patient. Patients were discharched from hospital within 6-24 hours. No ureteral stricture was encountered during the follow-up period. CONCLUSION: Our experience suggests that ureteroscopic interventions could be easily performed for all parts of ureter without previous dilatation of the ureter.

A case of primary ureteral carcinoma in association with unilateral complete duplication of the ureter.

We are presenting a 68-year-old female patient who was diagnosed to have a complete ureteral duplication and adenocarcinoma in the ureter which drained the upper moiety of the right kidney.

Does every retroperitoneal mass associated with undescended testicle represent testicular tumor or its metastasis?

We are presenting a 36 year old male patient who was diagnosed to have a right pararenal mass on CT scan taken for evaluation of his long lasting urinary stone disease and accompanying undescended right testicle. He subsequently underwent a retroperitoneal lymph node dissection for possible testicular tumor or its metastasis in the undescended testicle or retroperitoneal primary tumor, which came out to be non malignant tissue. We confirmed that the highest possible location of the testicle when undescended is at the level of the internal inguinal ring, and paracaval masses associated with undescended testicles do not necessarily represent a testicular tumor in the retained testicle, its metastasis or an extragonadal germ cell tumor (EGT), and further work should be done to illuminate the nature of such cases.

Effectiveness of Flexible Ureterorenoscopy and Laser Lithotripsy for Multiple Unilateral Intrarenal Stones Smaller Than 2 cm.

Purpose. To evaluate the safety and efficacy of RIRS for the treatment of multiple unilateral intrarenal stones smaller than 20 mm. Methods. Between March 2007 and April 2013, patients with multiple intrarenal stones smaller than 20 mm were treated with RIRS and evaluated retrospectively. Each patient was evaluated for stone number, stone burden (cumulative stone length), operative time, SFRs, and complications. Results. 173 intrarenal stones in 48 patients were included. Mean age, mean number of stones per patient, mean stone burden, and mean operative time were 40.2 ± 10.9 years (23-63), 3.6 ± 3.0 (2-18), 22.2 ± 8.4 mm (12-45), and 60.3 ± 22.0 minutes (30-130), respectively. The overall SFR was 91.7%. SFRs for patients with a stone burden less and greater than 20 mm were 100% (23/23) and 84% (21/25), respectively (χ (2) = 26.022, P < 0.001). Complications occurred in six (12.5%-6/48) patients, including urinary tract infection or high-grade fever >38.5°C in three cases, prolonged hematuria in two cases, and ureteral perforation in one case, all of whom were treated conservatively. No major complications occurred. Conclusions. RIRS is an effective treatment option in patients with multiple unilateral intrarenal stones especially when the total stone burden is less than 20 mm.

Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BACKGROUND: Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalance. OBJECTIVE: To compare the perioperative outcomes of patients undergoing extracorporeal urinary diversion (ECUD) and ICUD following robot-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS: We reviewed the database of the International Robotic Cystectomy Consortium (IRCC) (18 international centers), with 935 patients who had undergone RARC and pelvic lymph node dissection (PLND) between 2003 and 2011. INTERVENTION: All patients within the IRCC underwent RARC and PLND as indicated. The urinary diversion was performed either intracorporeally or extracorporeally. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic data, perioperative outcomes, and complications in patients undergoing ICUD or ECUD were compared. All patients had at least a 90-d follow-up. The Fisher exact test was used to summarize categorical variables and the Wilcoxon rank sum test or Kruskal-Wallis test for continuous variables. RESULTS AND LIMITATIONS: Of 935 patients who had RARC and PLND, 167 patients underwent ICUD (ileal conduit: 106; neobladder: 61), and 768 patients had an ECUD (ileal conduit: 570; neobladder: 198). Postoperative complications data were available for 817 patients, with a minimum follow-up of 90 d. There was no difference in age, gender, body mass index, American Society of Anesthesiologists grade, or rate of prior abdominal surgery between the groups. The operative time was equivalent (414 min), with the median hospital stay being marginally longer for the ICUD group (9 d vs 8 d, p=0.086). No difference in the reoperation rates at 30 d was noted between the groups. The 90-d complication rate was not significant between the two groups, but a trend favoring ICUD over ECUD was noted (41% vs 49%, p=0.05). Gastrointestinal complications were significantly lower in the ICUD group (p ≤ 0.001). Patients with ICUD were at a lower risk of experiencing a postoperative complication at 90 d (32%) (odds ratio: 0.68; 95% confidence interval, 0.50-0.94; p=0.02). Being a retrospective study was the main limitation. CONCLUSIONS: Robot-assisted ICUD can be accomplished safely, with comparable outcomes to open urinary diversion. In this cohort, patients undergoing ICUD had a relatively lower risk of complications.

How reliable is 12-core prostate biopsy procedure in the detection of prostate cancer?

INTRODUCTION: Prostate biopsies incur the risk of being false-negative and this risk has not yet been evaluated for 12-core prostate biopsy. We calculated the false-negative rate of 12-core prostate biopsy and determined the patient characteristics which might affect detection rate. METHODS: We included 90 prostate cancer patients (mean age of 64, range: 49-77) diagnosed with transrectal ultrasound guided 12-core prostate biopsy between December 2005 and April 2008. All patients underwent radical retropubic prostatectomy and the 12-core prostate biopsy procedure was repeated on surgical specimen ex-vivo. Results of preoperative and postoperative prostate biopsies were compared. We analyzed the influence of patient age, prostate weight, serum prostate-specific antigen (PSA) level, free/total PSA ratio, PSA density and Gleason score on detection rate. RESULTS: In 67.8% of patients, prostate cancer was detected with repeated ex-vivo biopsies using the same mapping postoperatively. We found an increase in PSA level, PSA density and biopsy Gleason score; patient age, decreases in prostate weight and free/total PSA ratio yielded higher detection rates. All cores, except the left-lateral cores, showed mild-moderate or moderate internal consistency. Preoperative in-vivo biopsy Gleason scores remained the same, decreased and increased in 43.3%, 8.9% and 47.8% of patients, respectively, on final specimen pathology. CONCLUSIONS: The detection rate of prostate cancer with 12-core biopsy in patients (all of whom had prostate cancer) was considerably low. Effectively, repeat biopsies can still be negative despite the patient's reality of having prostate cancer. The detection rate is higher if 12-core biopsies are repeated in younger patients, patients with high PSA levels, PSA density and Gleason scores, in addition in patients with smaller prostates, lower free/total PSA ratios.