Robotic versus standard laparoscopic partial/wedge nephrectomy: a comparison of intraoperative and perioperative results from a single institution.

PURPOSE: Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN) performed by two experienced laparoscopic surgeons. PATIENTS AND METHODS: We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). RESULTS: The mean tumor size was 2.3 cm (range 1.7-6.2 cm) for LPN and 3.1 cm (range 2.5-4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145-369 min) for LPN and 228.7 minutes (range 98-375 min) for RLPN (P=0.102). The mean estimated blood loss was 198 mL (range 75-500 mL) for LPN v 115 mL (25-300 mL) for RLPN (P=0.169). The mean warm ischemia time was 35.3 minutes (range 15-49 min) in the LPN group and 32.1 minutes (range 30-45 minutes) in the RLPN group (P=0.501). CONCLUSIONS: Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy.

Combined robot-assisted laparoscopic nephroureterectomy and radical prostatectomy.

A 57-year-old man with prostate cancer and transitional-cell carcinoma of the kidney underwent a combined robot-assisted prostatectomy and hand-assisted laparoscopic nephroureterectomy with robot assistance. We describe the initial report of this combined operation and the novel use of the da Vinci robot for extravesical bladder-cuff excision and repair.

Initial experience with full-length metal stent to relieve malignant ureteral obstruction.

Ureteral obstruction caused by extrinsic compression by a malignancy generally can be overcome initially with a ureteral stent. However, the long-term failure rate is high, usually necessitating placement of a nephrostomy tube. Herein, we present the initial case, in this country, of intractable ureteral obstruction managed successfully with the newly developed all-metal Resonance stent (Cook Ireland Ltd., Limerick, Ireland) constructed of MP35N alloy, a composite of nonmagnetic nickel-cobalt-chromium-molybdenum. The patient is a 64-year-old woman with metastatic breast cancer causing retroperitoneal fibrosis and ureteral obstruction diagnosed laparoscopically. The obstruction failed to respond to placement of a single 7F double-J stent and then of two 6F double-J stents in the left ureter. As a last resort, in order to avoid nephrostomy-tube placement, the 6F metal stent was placed; this provided unobstructed flow of urine, as documented on a subsequent Whitaker test and, most recently, on a renal scan, 4 months after initial stent placement.

Nerve-sparing techniques in open and laparoscopic prostatectomy.

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.

Expression of matrix metalloproteinase-2 and -9 and their inhibitors, tissue inhibitor of metalloproteinase-1 and -2, in primary cultures of human prostatic stromal and epithelial cells.

The production of matrix metalloproteinases (MMPs) by prostatic epithelial and/or neighboring stromal cells is considered to be a property that gives cells the capability to penetrate extracellular matrix barriers in normal or neoplastic growth. In order to examine the role of MMPs in the prostate, we evaluated the expression of MMP-2 and -9 and the tissue inhibitors of matrix metalloproteinases (TIMP)-1 and -2 in primary cultures of prostatic stromal and epithelial cells. These cells were isolated from normal tissues of the different zones of the prostate, from benign prostatic hyperplasia (BPH) and from cancer. Stromal cells, regardless of tissue of origin, secreted the 72-kDa proenzyme form of MMP-2, whereas conditioned media (CM) from epithelial cells demonstrated little/no pro-MMP-2 as examined by zymography. Either type of cell did not secrete MMP-9. RT-PCR evaluation showed stromal cells expressed transcripts for MMP-2, but not for MMP-9. Transcripts for MMP-9 were detected in epithelial cells, although no MMP-9 activity was detected in their CM. Treatment of stromal cells with 1 or 10 ng/ml of transforming growth factor-beta (TGF-beta) moderately increased secretion of pro-MMP-2 protein with little change in MMP-2 RNA. However, treatment of epithelial cells with TGF-beta induced expression and secretion of both MMP-2 and-9. The effect of TGF-beta on expression of MMPs by epithelial cells was not duplicated or affected by treatment with insulin-like growth factor (IGF)-1, epidermal growth factor (EGF), platelet-derived growth factor (PDGF), or basic fibroblast growth factor (bFGF). Stromal cells expressed transcripts of both TIMP-1 and -2. Epithelial cells expressed TIMP-1, but little TIMP-2. TGF-beta did not regulate the expression of TIMP-1 or -2 in either stromal or epithelial cells. Our results suggest that the elevated levels of MMP-2 and -9 observed in prostate development and cancer may be due to the elevated TGF-beta associated with these tissues.