Functional outcomes following external beam radiation therapy for patients with prior holmium laser enucleation of the prostate.

INTRODUCTION/BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is an increasingly popular size-independent technique of treating male voiding dysfunction due to benign prostatic hypertrophy. Some patients after HoLEP may develop clinically significant prostate cancer and opt for definitive treatment with external beam radiation therapy (EBRT). Little is known about the safety of EBRT after HoLEP and how it may functionally impact voiding after HoLEP has altered the anatomy of the prostate. Our study aimed to assess patient-reported voiding outcomes following EBRT after HoLEP with a focus on incontinence related patient outcomes. METHODS/MATERIALS: This study was conducted with approval from our hospital's institutional review board. Patients that underwent HoLEP followed by EBRT were identified and data were collected in a retrospective nature from a single surgeon HoLEP cohort over the past 4 years (2019-2023). Patient demographics, disease and radiation therapy characteristics, radiation therapy, and baseline voiding symptoms were recorded. Current functional voiding outcomes were also collected via phone-call or portal communication in a cross-sectional manner with questions pertaining to type of incontinence, IPSS quality of life score, and administration of the Michigan incontinence symptom index (M-ISI). Adverse events encountered during follow-up were recorded. RESULTS: 24 patients were identified who received RT for prostate cancer after HoLEP with an average age of 73.6 (± 5.3). One third of patients reported no incontinence whatsoever after radiation and of those who experienced incontinence, the majority felt that it was not worsened after radiation. Median IPSS QoL score following radiation was 1 (range 0-6), median M-ISI Severity Score was 4 out of a maximum of 32, and median M-ISI bother score was 0 out of a maximum of 8. One patient developed a bladder neck contracture (BNC) approximately 1 year following his radiation therapy (approximately 18 months after HoLEP) causing bothersome incontinence and LUTS. CONCLUSIONS: In our cohort most patients who received RT after HoLEP reported a high urinary-symptom related quality of life and a low rate of urinary incontinence. One patient who received SBRT suffered a BNC which is a known adverse event with RT but given our small sample size it remains unclear if the risk is higher in patients receiving RT after HoLEP. Larger studies should focus on examining the rate of bladder neck contracture in patients receiving RT after HoLEP, particularly focusing on whether the degree of dose fractionation may impact their development.

Timing interval from peri-prostatic block to biopsy impacts procedural pain.

INTRODUCTION: To compare visual analog scale (VAS) pain scores between patients with a 2-minute versus 10-minute delay of peri-prostatic lidocaine injection prior to transrectal ultrasound-guided prostate biopsies (TRUS-bx). MATERIALS AND METHODS: Eighty patients who underwent standard 12-core TRUS-bx by a single surgeon were prospectively randomized into four different treatment arms: bibasilar injection with a 2-minute delay, bibasilar injection plus a single apical injection with a 2-minute delay, bibasilar injection with a 10-minute delay, and bibasilar injection plus a single apical injection with a 10-minute delay. Patients were asked to report their level of pain on the VAS (0-10, with 10 indicating unbearable pain) at the following intervals: probe insertion (baseline), after each core, and post-procedure. The primary outcome measure was mean VAS score across all 12 cores minus baseline VAS score, which we refer to baseline-adjusted mean VAS score. RESULTS: Baseline-adjusted mean VAS score was significantly higher for the 2-minute delay group compared to the 10-minute delay group (mean: -0.7 versus -1.6, p = 0.025). Subset analysis of biopsies 1-3, 4-6, 7-9 and 10-12 also demonstrated higher baseline-adjusted mean VAS scores in the 2-minute delay group (all p ≤ 0.043). CONCLUSIONS: Lower TRUS-bx VAS scores can be achieved by extending the time from lidocaine injection to onset of prostate biopsy from 2 to 10 minutes.

Racial, ethnic, and socioeconomic disparities in rates of stage IV prostate cancer after USPSTF category "D" recommendation against prostate-specific antigen screening: a retrospective cohort study.

Background: In 2012 the United States Preventative Services Task Force (USPSTF) changed its prostate-specific antigen (PSA) screening recommendation to a category "D". The purpose of this study is to examine racial, ethnic, and socioeconomic differences in risk of presentation with metastatic prostate cancer (mPCa) at time of diagnosis before and after the 2012 USPSTF category "D" recommendation. Methods: This is a population-based cohort study. We identified patients with mPCa at diagnosis within the National Cancer Database from 2004-2017. Logistic regression models were used to examine associations of mPCa with age, race, ethnicity, geographic location, education level, income, and insurance status. Linear regression models assuming underlying binomial distribution were fitted to annual percentage of mPCa at diagnosis for years 2012-2017 to evaluate the post category "D" recommendation era. Results: From 2004 to 2017, 88,987 patients presented with mPCa. A higher percentage of mPCa was noted post-USPSTF category "D" recommendation, with a disproportionately greater increase observed among Hispanics and non-Hispanic Blacks [Δslope/year: Hispanics (0.0092), non-Hispanic Blacks (0.0073) and non-Hispanic Whites (0.0070)]. Insurance status impacts race/ethnicity differently: uninsured Hispanics were 3.66 times more likely to present with mPCa than insured Hispanics, while uninsured non-Hispanic Blacks were 2.62 times more likely to present with mPCa than insured non-Hispanic Blacks. Household income appears to be associated with differences in mPCa, particularly among non-Hispanic Blacks. Those earning <$30,000 were more likely to present with mPCa compared to higher income brackets. Conclusions: Since the USPSTF grade "D" recommendation against PSA screening, the percentage of mPCa at diagnosis has increased, with a higher rate of increase among Hispanic and non-Hispanic Blacks compared to non-Hispanic Whites.

Erosion of inferior vena caval filter noted during robotic assisted laparoscopic partial nephrectomy.

Inferior Vena Cava (IVC) filters are mechanical devices implanted to provide prophylaxis against pulmonary emboli in patients for whom standard anticoagulation is either inadequate or contraindicated. A 67-year-old female with a 10-year-old indwelling IVC filter underwent robotic assisted laparoscopic partial nephrectomy for a right upper pole renal mass. Renal hilum dissection was complicated by adhesions secondary to eroded IVC filter struts. IVC filter erosion is a well-described phoenomena in both the radiologic and surgical literature. As many as 25% of filters are noted to be radiographically eroded; however, the incidence of clinically significant erosion is much less. Given the placement of endovascularly delivered IVC filters in close proximity to many urologic operative fields, it is important for urologists to be aware of the potential of eroded devices when pursuing para-caval dissections.

Vasectomy Simulation Curriculum and Trainer with Enhanced Face, Content and Construct Validity.

INTRODUCTION: We assessed the face, content and construct validity of a newly created vasectomy simulation module. METHODS: Pre-simulation and post-simulation surveys quantifying simulation effectiveness, impact on confidence level and critiques of the overall design were obtained in July 2015 to assess face and content validity. Residents were subdivided based on year of residency and construct validity was ascertained via a 20-objective checklist and individual Likert score as graded by a single attending physician in a blinded fashion. RESULTS: Two medical students and 8 residents (2 Pre-Urology, 2 Uro-1, 2 Uro-2 and 2 Uro-3) were included in the analysis. The response rate was 100% (10 of 10) for the simulation exercise and all residents (100%, 8 of 8) were used in the metric data analysis. Simulation increased the confidence to perform a vasectomy independently on average 1.58 points based on pre-simulation and post-simulation questionnaire analysis (95% CI 1.09-2.89, p=0.02). Training year had a significantly positive association (overall p <0.01) with number of objectives completed. CONCLUSIONS: Our enhanced vasectomy simulation module demonstrated excellent face, content and construct validity.

Evaluation of the association of current cigarette smoking and outcome for patients with clear cell renal cell carcinoma.

OBJECTIVES: Cigarette smoking is a well known risk factor for the development of renal cell carcinoma (RCC); however, its association with tumor aggressiveness and patient outcome remains in question. Herein, we test the hypothesis that cigarette smoking is associated with a more aggressive phenotype and poorer outcome among patients with RCC. METHODS: We examined data on 2242 patients treated with radical nephrectomy or nephron-sparing surgery for unilateral, sporadic, clear cell RCC at Mayo Clinic Rochester between 1970 and 2002. Associations of self-reported smoking status with death from RCC were assessed using Cox proportional hazards regression models summarized with hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: While former cigarette smoking was not associated with an increased risk of RCC death, current cigarette smokers were 31% more likely to die from RCC compared with non-smokers on a hazard ratio scale (HR 1.31; 95% CI 1.09-1.58; P = 0.004). Interestingly, current smokers were more likely to present with advanced disease (i.e. later TNM stage) compared with both former and never smokers. After adjustment for TNM stage group and tumor grade, there was no longer a statistically significant increase in the risk of death from RCC for current cigarette smokers (HR 0.99; 95% CI 0.82-1.19; P = 0.875). CONCLUSIONS: Patients who report current smoking at time of surgery are at increased risk of RCC death; however, this association is attenuated after adjustment for standard pathological indices and is therefore of little prognostic value. Nevertheless, the association of current smoking with more advanced disease at presentation (e.g. metastatic spread) warrants further investigation.

Impact of Minimally Invasive Benign Prostatic Hyperplasia Therapies on 30- and 90-Day Postoperative Office Encounters.

OBJECTIVE: To compare the frequency of postoperative encounters in the 30-day and 90-day postoperative periods for various bladder outlet obstruction surgical therapies. MATERIALS AND METHODS: All patients who underwent transurethral resection of the prostate (TURP), GreenLight laser photovaporization of the prostate (GL-PVP) (American Medical Systems Inc.), and holmium laser enucleation of the prostate (HoLEP) from January 1, 2012 to December 31, 2014 were followed for 6 months postoperatively. All postoperative encounters such as patient calls or questions, catheter exchanges or removals, and hospital-based readmissions or emergency department visits were recorded in the electronic medical record. RESULTS: Two hundred and ninety-one consecutive patients underwent outlet procedures during the study period: TURP (N = 199; mean age, 71 years; mean body mass index [BMI], 28.5), HoLEP (N = 60; mean age, 68 years; mean BMI, 28.1), or GL-PVP (N = 32; mean age, 72 years; mean BMI, 29.3). No statistically significant difference was observed for age, BMI, preoperative American Urological Association symptom score, or preoperative maximum flow velocity between the 3 groups. Thirty-day postoperative encounters differed significantly between the 3 surgery types (P < .001). Specifically, there were fewer encounters within 30 days of surgery for TURP compared to both HoLEP (≥1 encounter: TURP = 48.7%, HoLEP = 66.7%; P = .006) and GL-PVP (≥1 encounter: TURP = 48.7%, GL-PVP = 93.7%; P < .001). The number of encounters within 90 days postoperatively was also significantly lower for TURP patients (P < .001). CONCLUSION: TURP results in fewer postoperative encounters in both the 30-day and 90-day postoperative periods compared to HoLEP and GL-PVP. Laser prostate therapies may place increased burden on clinic staff during the 30-day and 90-day postoperative periods.

Comparison of daily megavoltage electronic portal imaging or kilovoltage imaging with marker seeds to ultrasound imaging or skin marks for prostate localization and treatment positioning in patients with prostate cancer.

PURPOSE: To compare the accuracy of imaging modalities, immobilization, localization, and positioning techniques in patients with prostate cancer. METHODS AND MATERIALS: Thirty-five patients with prostate cancer had gold marker seeds implanted transrectally and were treated with fractionated radiotherapy. Twenty of the 35 patients had limited immobilization; the remaining had a vacuum-based immobilization. Patient positioning consisted of alignment with lasers to skin marks, ultrasound or kilovoltage X-ray imaging, optical guidance using infrared reflectors, and megavoltage electronic portal imaging (EPI). The variance of each positioning technique was compared to the patient position determined from the pretreatment EPI. RESULTS: With limited immobilization, the average difference between the skin marks' laser position and EPI pretreatment position is 9.1 +/- 5.3 mm, the average difference between the skin marks' infrared position and EPI pretreatment position is 11.8 +/- 7.2 mm, the average difference between the ultrasound position and EPI pretreatment position is 7.0 +/- 4.6 mm, the average difference between kV imaging and EPI pretreatment position is 3.5 +/- 3.1 mm, and the average intrafraction movement during treatment is 3.4 +/- 2.7 mm. For the patients with the vacuum-style immobilization, the average difference between the skin marks' laser position and EPI pretreatment position is 10.7 +/- 4.6 mm, the average difference between kV imaging and EPI pretreatment position is 1.9 +/- 1.5 mm, and the average intrafraction movement during treatment is 2.1 +/- 1.5 mm. CONCLUSIONS: Compared with use of skin marks, ultrasound imaging for positioning provides an increased degree of agreement to EPI-based positioning, though not as favorable as kV imaging fiducial seeds. Intrafraction movement during treatment decreases with improved immobilization.

Urologic-Induced Complications of Prophylactic Ureteral Localization Stent Placement for Colorectal Surgery Cases.

PURPOSE: A prophylactic ureteral localization stent (PULSe) placed by urologists aids in intraoperative localization and detection of suspected ureteral injury during complex colorectal surgery (CRS) cases. We evaluated the incidence and management of urologic-induced complications secondary to PULSe placement during CRS cases at a single center. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent cystoscopy and PULSe placement at the time of CRS over a 12-month period. Bilateral 5 French ×70-cm TigerTail® (Bard Medical Division, Covington, GA) PULSe devices were placed without assistance of routine fluoroscopy. RESULTS: Ninety-nine patients (mean age, 58.1 years; range, 17-88 years) underwent bilateral PULSe placement, with a male:female ratio of 44:55 and a mean body mass index of 26.8 (17.0-38.6) kg/m(2). Mean pre- and postprocedural creatinine levels were 0.91 and 1.01 mg/dL, respectively. Twenty-two of 99 (22%) cases utilized a guidewire to aid in placement of PULSe. Four Clavien grade IIIb complications occurred: mucosal edema, reflex anuria, ureteral perforation, and ureteral obstruction secondary to significant clot burden. Three of the grade IIIb complications were managed endoscopically with double-J stent placement. The ureteral perforation case required percutaneous nephrostomy tube placement. Subgroup analysis of the four grade IIIb complications revealed a mean age of 62.3 years, body mass index of 26.98 kg/m(2), and pre- and postprocedural creatinine levels of 0.95 and 4.83 mg/dL, respectively. Only one of the four grade IIIb complications utilized a guidewire prior to PULSe placement. CONCLUSIONS: The incidence of Clavien grade III urologic-induced complications during PULSe placement is approximately 2% (4/188). Mandatory adoption of fluoroscopy and guidewires may be required to minimize complications of PULSe placement.

Acute urinary retention after transperineal template-guided prostate biopsy.

PURPOSE: Urinary retention occurs in 5%-36% of patients with prostate cancer after implantation of radioactive seeds for brachytherapy. We used transperineal biopsy as a model to determine the influence of needle trauma on urinary retention. METHODS AND MATERIAL: We retrospectively reviewed medical records of 157 men with high risk of prostate cancer who underwent systematic ultrasound-guided biopsy of the prostate with the transperineal template technique and an 18-gauge automated biopsy device. RESULTS: Eighteen of 157 patients (11.5%; 95% confidence interval, 6.9%-17.5%) had urinary retention within 48 hours after biopsy. Median age was 68.5 years in patients with retention vs. 67.0 years in patients without (p = 0.319); median calculated prostate volume, 76.5 vs. 51.5 mL (p = 0.015); and median number of biopsy cores, 22.0 vs. 20.0 (p = 0.038). Age distribution differed between groups (p = 0.047), with more younger men in the no-retention group. On multivariate analysis, only number of biopsy cores significantly predicted urinary retention (p = 0.003). Four patients required transurethral resection; 1 had an indwelling catheter until radical prostatectomy; and 13 were catheter-free within 1-5 days. CONCLUSIONS: Needle trauma alone may cause urinary retention in men undergoing transperineal procedures. The number of needle incursions and prostate size are predictors of postprocedure urinary retention.

Prediction of genitourinary tract morbidity after brachytherapy for prostate adenocarcinoma.

OBJECTIVE: To investigate whether preoperative genitourinary variables in patients undergoing brachytherapy for localized prostate adenocarcinoma could predict postoperative genitourinary tract morbidity. PATIENTS AND METHODS: We retrospectively reviewed medical records of 105 men who received either iodine 125 or palladium 103 radioactive seed implants with or without external beam radiotherapy or hormone blockade from January 1, 1998, through December 31, 2000, at the Mayo Clinic in Jacksonville, Fla. Patients with one or more of the following were classified as having a high risk of postoperative genitourinary tract morbidity: American Urological Association symptom scores greater than 15, maximum urinary flow rate less than 10 mL/s, postvoid residual urinary volume greater than 100 mL, or prostate volume greater than 40 cm3. Of the 105 men, 59 (56%) were classified as high risk and 46 (44%) as low risk. Mean follow-up after brachytherapy was 23.6 months. Modified Radiation Therapy Oncology Group scores were used to assess postoperative genitourinary tract morbidity. The term significant genitourinary tract morbidity was applied to patients with a Radiation Therapy Oncology Group grade of 3 or 4 after at least 6 months of follow-up. RESULTS: Significant morbidity occurred in 37% of high-risk vs 15% of low-risk patients (P = .006). In high-risk patients, transurethral resection or incision of the prostate was required in 5 patients, urethral dilation in 4, direct-vision internal urethrotomy in 1, and placement of a suprapubic catheter in 1. In low-risk patients, transurethral incision of the prostate was required in only 1 patient. Urinary flow rate was a significant individual predictor of postoperative morbidity (P = .03). CONCLUSIONS: A combination of urinary flow rate, prostate volume, postvoid residual urinary volume, and American Urological Association symptom score can help identify patients with underlying voiding dysfunction. Urinary flow rate was a statistically significant predictor of genitourinary tract morbidity after brachytherapy for localized prostate adenocarcinoma. Patients and physicians should consider these factors before a patient decides to undergo brachytherapy.

Simulation-based training for bedside assistants can benefit experienced robotic prostatectomy teams.

PURPOSE: We designed a three-phase bedside assistant training course for those involved with robot-assisted radical prostatectomy (RARP). We also examined whether an experienced RARP team (>1000 cases) would perceive benefit from this three-phase bedside assistant training course. MATERIALS AND METHODS: The 13 RARP bedside assistants were identified at our institution (three surgical technicians, two surgical assistants, four resident trainees, and four physician assistants). The course consisted of three phases that were taught at three separate morning sessions. Phase 1 focused on robot functionality. Phase 2 consisted of a step-by-step video session that focused on the assistant's role in each RARP step. Phase 3 involved three hands-on laparoscopic drills that were to be completed in a predetermined period. Pre- and postcourse questionnaires assessed learner knowledge pertaining to RARP. RESULTS: All 13 learners completed the three-phase training course. Nine of 13 learners thought this course would be beneficial, although, 9 of 13 already thought that they were good RARP assistants before the course. Ten of 13 learners were able to complete the hands-on drills in the predetermined periods. On completion of the course, every learner thought the course was beneficial and that it should be repeated annually. Twelve of 13 thought that the course made them a better assistant and that their intra-abdominal spatial orientation was greatly improved. Seven of the learners thought the hands-on drills were the most beneficial portion of the course, while the other six found the step-by-step lecture the most beneficial. CONCLUSIONS: A three-phase hands-on RARP bedside assistant training course is beneficial to and desired by an experienced RARP team at least annually.

Expression of endothelin 2 and localized clear cell renal cell carcinoma.

Despite the rising incidence of clear cell renal cell carcinoma, the molecular events that support its development and progression remain unclear. Herein, we evaluate the association of endothelin 2 expression with both clear cell renal cell carcinoma development and progression-free survival. We conducted real-time polymerase chain reaction to determine endothelin 2 expression levels on 238 patients who underwent nephrectomy for localized clear cell renal cell carcinoma, 161 of whom also had adjacent normal kidney samples available for analysis. To evaluate associations with clear cell renal cell carcinoma development, linear mixed models were used to compare differential expression between tumor and a normal kidney as well as to explore interactions with clinicopathologic features. To evaluate associations with prognosis, Cox proportional hazards models were used to assess the association of progression-free survival and endothelin 2 expression in tumor tissue. Overall, endothelin 2 expression was higher in tumor samples versus patient-matched normal kidney samples, with an average fold change of 1.99 (95% confidence interval, 1.48-2.60; P < .0001). This overexpression in tumor versus normal kidney samples was more pronounced in low- compared with high-grade tumors (interaction, P = .0002), in early- compared with late-stage tumors (interaction, P = .001), and in tumors without compared with those with necrosis (interaction, P = .001). Moreover, an increasing endothelin 2 expression in tumors was associated with a longer progression-free survival (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .03); however, after controlling for known clinicopathologic factors, this association was attenuated (hazard ratio, 0.99; 95% confidence interval, 0.89-1.09; P = .7). Up-regulation of endothelin 2 is a common and early event in localized clear cell renal cell carcinoma. Higher tumor expression of endothelin 2 is associated with a longer progression-free survival but not after adjustment for well-known pathologic indices. Thus, although endothelin 2 does not appear to be an independent prognostic marker, there is evidence of a putative role in clear cell renal cell carcinoma progression. If supportive mechanistic data can be produced, endothelin 2 could represent a potential target for chemopreventive or neoadjuvant therapeutics for clear cell renal cell carcinoma.

Robot-assisted laparoscopic reconstruction of retrocaval ureter: description and video of technique.

Ureteral obstruction secondary to retrocaval ureter is rarely reported in the urologic literature. Symptomatic retrocaval ureters usually present in the 3rd and 4th decade of life. Standard treatment involves ureteroureterostomy approximating the ureter anterior to the vena cava. We describe the initial presentation, imaging, port placement, and operative technique including video presentation of a robot-assisted laparoscopic repair of a retrocaval ureter.

Use of the Habib 4 × radiofrequency-assisted bipolar hemostatic device to avoid warm ischemia in select large partial nephrectomies: description and video of technique.

OBJECTIVES: The Habib 4 × radiofrequency-assisted bipolar hemostatic device (AngioDynamics) was used during select open partial nephrectomies to minimize blood loss and prevent warm renal ischemia. The article and video demonstrate this novel technique for partial nephrectomies in select renal masses. METHODS: Patients with large renal tumors requiring partial nephrectomy where avoidance of warm ischemia was deemed imperative underwent open partial nephrectomy at our institution utilizing the Habib 4 × radiofrequency ablation device to avoid prolonged warm ischemia time and prevent blood loss. RESULTS: We have used the device successfully in 4 partial nephrectomies (2 patients with solitary kidneys, 2 patients with bilateral large masses). The mean age was 65 years. Mean tumor size was 6.4 cm. All tumors were located either in the upper pole or lower pole of the kidney. Mean hospital stay was 4.6 days. No patient received an intraoperative blood transfusion. Two patients required long-term ureteral stenting and surgical drainage for urine leakage. CONCLUSIONS: Bipolar radiofrequency ablation offers avoidance of hilar clamping in carefully selected large partial nehrectomies.

Robotic-assisted bladder diverticulectomy: tips and tricks.

INTRODUCTION: The da Vinci Surgical System has become extremely popular in the field of urology for procedures requiring complex reconstructive maneuvers, such as radical prostatectomy and pyeloplasty. A natural extension of these procedures is the use of the da Vinci system for complex urinary tract reconstruction deep in the pelvis, such as bladder diverticulectomy. TECHNICAL CONSIDERATIONS: In our report and accompanying Video, we have demonstrated some technical tips and tricks with regard to patient selection, preoperative imaging, patient positioning, port placement, intraoperative diverticulum recognition/excision, and cystotomy repair that the surgeon might find beneficial for successful completion of robotic-assisted bladder diverticulectomy. CONCLUSIONS: The tips and tricks we have presented might aid in the successful completion of robotic bladder diverticulectomy.

Evaluation of pancreatic damage after extracorporeal shock wave lithotripsy, percutaneous stone surgery, and ureteroscopy.

OBJECTIVES: To complete a prospective evaluation of serum amylase and lipase levels before and after shock wave lithotripsy (SWL) for renal stones. We also compared these serum levels to those of patients undergoing percutaneous and ureteroscopic stone surgery. SWL injury to the pancreas should be noted by an increase in serum amylase and lipase. METHODS: A prospective evaluation of 38 patients (16 who underwent SWL, 15 who underwent percutaneous nephrostolithotomy, and 7 who underwent ureteroscopic stone manipulation) who underwent treatment of renal calculi at our institution was completed. The control group was the combined group of patients who had undergone percutaneous nephrostolithotomy or ureteroscopic stone manipulation. The serum amylase and lipase levels were measured before the procedure, immediately after the procedure (2 hours), and ≥30 days after the procedure. RESULTS: No statistically significant difference was found in the change from before to immediately after the procedure between the SWL group and the controls in amylase (median decrease 6 U/L vs 11 U/L, P = .45) or lipase (median decrease 4 U/L vs 9 U/L, P = .31). Also, no statistically significant evidence was seen in the change from before to >30 days after the procedure between the SWL group and controls in the amylase level (median increase 0 U/L vs 2 U/L, P = 1.00) or lipase (median change 2 U/L increase vs 1 U/L decrease, P = .96). CONCLUSIONS: SWL does not appear to noticeably increase the serum amylase and lipase level directly postoperatively or >30 days after the procedure compared with baseline or compared with the controls.

Robotic-assisted laparoscopic reconstruction of the upper urinary tract: tips and tricks.

OBJECTIVES: To examine whether simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been widely accepted by urologists for complex reconstructive maneuvers such as radical prostatectomy and pyeloplasty. METHODS: The manuscript and accompanying video outline tips and tricks for patient selection, patient evaluation, port placement, dissection techniques, robotic docking, ureteral repair, and stent management for complex urinary tract reconstruction of the upper urinary tract from the level of the renal calyx to the bladder. RESULTS: Modifications such as port placement, robotic docking techniques, and ureter reconstruction have simplified the technique of complex robotic-assisted laparoscopic reconstruction of the urinary tract. CONCLUSIONS: Numerous scenarios can be encountered during robotic-assisted laparoscopic repair of the upper urinary tract. Simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder.

Safety and peri-operative outcomes during learning curve of robot-assisted laparoscopic prostatectomy: a multi-institutional study of fellowship-trained robotic surgeons versus experienced open radical prostatectomy surgeons incorporating robot-assisted laparoscopic prostatectomy.

PURPOSE: To analyze and compare the safety and peri-operative outcomes of fellowship-trained robotic surgeons (FEL) and experienced open surgeons (OE) incorporating robot-assisted laparoscopic prostatectomy (RALP) into practice. MATERIALS AND METHODS: Multiinstitutional, prospective data were collected on the first 30 RALP performed by FEL and OE (defined as over 1000 prostatectomies) incorporating RALP into practice. Morbidity from the peri-operative course was evaluated as were operative outcomes. The second 30 cases from the OE group were evaluated to assess for improvement with experience. RESULTS: There were no rectal injuries or death in either group. Blood transfusion rates did not differ between the two groups (2% vs. 3%, p = 0.65). Open conversion occurred three times in the OE group but only within the first 30 cases. In the first 30 cases FEL had statistically lower rates of positive margins (15% vs. 34%, p = 0.008) and decreased likelihood of prolonged urethral catheter leakage (5% vs. 19%, p = 0.009). The FEL group had lower rates of failure of prostate-specific antigen to nadir < 0.15 ng/mL (2% vs. 10%, p = 0.056). There were no reoperations in the FEL group but present in 2% of the OE group initially. The second 30 cases of the OE group noted a statistical improvement for all parameters with margin rates and the requirement of prolonged catheterization becoming statistically comparable to those of the FEL group. CONCLUSIONS: OE can safely incorporate RALP into practice and achieve outcomes comparable to FEL quickly. As anticipated, FEL achieve these endpoints earlier in their practice.

Robot-assisted laparoscopic excision of bladder wall leiomyoma.

Leiomyoma is the most frequent nonepithelial benign tumor of the bladder, and only about 170 cases have been reported in the literature. Most bladder wall leiomyomas are found incidentally and can be clinically followed if imaging and biopsy findings are consistent with the diagnosis. Resection is usually performed for symptomatic or enlarging masses and is indicated if the diagnosis is in question. We demonstrate imaging characteristics, port placement, operative technique, and surgical pathologic findings of the first reported case of robot-assisted laparoscopic resection of a bladder wall leiomyoma.