Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

OBJECTIVES: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS: Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.

Multicenter international experience of 532 nm-laser photo-vaporization with Greenlight XPS in men with large prostates (prostate volume > 100 cc).

PURPOSE: To evaluate the outcomes and durability of photoselective vaporization of the prostate (PVP) using the XPS-180 system in patients with a large prostate volume (PV) > 100 cc at 4 years of follow-up in a large, multicenter experience. METHODS: 438 men with pre-operative transrectal ultrasound (TRUS) PV > 100 cc were treated in eight experienced centers in Canada, USA, and in France with the Greenlight XPS laser using PVP for the treatment of symptomatic BPH. IPSS, Qmax, postvoid residual (PVR), and prostate-specific antigen (PSA) were measured at 6, 12, 24, 36, and 48 months. Durability was evaluated using BPH retreatment rate at 12, 24, and 36 months. RESULTS: Median PV and PSA were 121 cc and 6.3 ng/dl. Indwelling catheter at the time of surgery was observed in 37% of men. Median operative, laser time, and energy applied were 90 min, 55 min, and 422 kJ, respectively. Median energy delivery was 3.4 kJ/cc of prostate per case. Outpatient surgery was feasible with median length of stay at 24 h. IPSS, Qmax and PVR were significantly improved at all endpoints including at 48 months. Moreover, surgical BPH retreatment rates were 5.4 and 9.3% at 24 and 36 months. Interestingly, characteristics of retreated men include: energy delivery 2.4 vs. 3.4 kJ/cc of prostate (p = 0.02) and PSA reduction at 12 months 26 vs. 51% (p = 0.02). CONCLUSIONS: PVP using Greenlight XPS-180W can potentially provide durable improvements with regard to functional outcomes at 4 years. However, rising retreatment rates after 3 years is of concern. This highlights the imperative need of utilizing a standardized surgical technique (enucleation-like-defect) and an optimal energy density >3KJ/cc.

Assessment of energy density usage during 180W lithium triborate laser photoselective vaporization of the prostate for benign prostatic hyperplasia. Is there an optimum amount of kilo-Joules per gram of prostate?

OBJECTIVES: To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate-specific antigen (PSA) reduction and complications. PATIENTS AND METHODS: After exclusions, a total of 440 patients who underwent GreenLight (tm) laser XPS-180W lithium triborate PVP for the treatment of BPH were retrospectively reviewed. Data were collected from seven different international centres (Canada, USA, UK and France). Patients were stratified into four energy density groups (kJ/mL) according to intra-operative energy delivered and prostate volume as determined by preoperative transrectal ultrasonography (TRUS): group 1: <3 kJ/mL; group 2: 3-5 kJ/mL; group 3: 5-7 kJ/mL; and group 4: ≥7 kJ/mL. Energy density groups were chosen arbitrarily. PSA reduction and functional outcomes (International Prostate Symptom Score, quality of life, post-void residual urine volume, maximum urinary flow rate) were compared at 6, 12 and 24 months. Peri-operative complications and retreatment rates were also compared among the groups. RESULTS: The PSA reduction rates at 24 months after the procedure were 51, 61, 79 and 83% for the energy density groups <3, 3-5, 5-7 and ≥7 kJ/mL, respectively (P ≤ 0.01). This held true after accounting for baseline confounders. Energy density was not associated with higher complication rates, including haematuria, stricture formation, incontinence, refractory urinary retention, urinary tract infection and conversion to transurethral resection of the prostate. Functional outcomes at 2 years of follow-up were equivalent among the groups (P > 0.05 for all) and similar retreatment rates were observed (P = 0.36). CONCLUSION: Higher energy usage per cc of prostate was associated with a more significant reduction in PSA level (>50%) at 6, 12 and 24 months, suggesting increased vaporization of adenoma tissue; however, this did not translate into differences in functional outcomes at 2-year follow-up.

Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes.

PURPOSE: We evaluated photoselective vaporization of the prostate using the GreenLight™ XPS™ 180 W system for benign prostatic hyperplasia treatment in a large multi-institutional cohort at 2 years. We particularly examined safety, outcomes and the re-treatment rate in larger prostates, defined as a prostate volume of 80 cc or greater, to assess the potential of photoselective vaporization of the prostate as a size independent procedure. MATERIALS AND METHODS: A total of 1,196 patients were treated at 6 international centers in Canada, the United States, France and England. All parameters were collected retrospectively, including complications, I-PSS, maximum urinary flow rate, post-void residual urine, prostate volume, prostate specific antigen and the endoscopic re-intervention rate. Subgroup stratified comparative analysis was performed according to preoperative prostate volume less than 80 vs 80 cc or greater on transrectal ultrasound. RESULTS: Median prostate size was 50 cc in 387 patients and 108 cc in 741 in the prostate volume groups less than 80 and 80 cc or greater, respectively. The rate of conversion to transurethral prostate resection was significantly higher in the 80 cc or greater group than in the less than 80 cc group (8.4% vs 0.6%, p <0.01). I-PSS, quality of life score, maximum urinary flow rate and post-void residual urine were significantly improved compared to baseline at 6, 12 and 24 months of followup without significant differences between the prostate size groups. The re-treatment rate at 2 years reported in 5 of 411 patients was associated with the delivery of decreased energy density (2.1 vs 4.4 kJ/cc) in the group without re-treatment. CONCLUSIONS: Photoselective vaporization of the prostate using the XPS 180 W system is safe and efficacious, providing durable improvement in functional outcomes at 2 years independent of prostate size when treated with sufficient energy.

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVE: To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction (UPJO), proximal, and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between April 2012 and December 2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of P <.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (P ≤.05 was considered statistically significant). RESULTS: Overall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% vs 25.7%, P <.01) and a higher proportion of patients who underwent ureteral rest (74.3% vs 48.6%, P <.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times ((confidence interval) CI 1.26-7.54, P = .01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, P = .01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION: Surgical success of RUR for management of UPJO, proximal, and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

Incidence of renal artery pseudoaneurysm following open and minimally invasive partial nephrectomy: a systematic review and comparative analysis.

PURPOSE: Partial nephrectomy is performed for renal masses as a means of preserving renal function. Renal artery pseudoaneurysm is a potential complication of partial nephrectomy. We determined the incidence of renal artery pseudoaneurysm after open and minimally invasive partial nephrectomy, and performed a comparative analysis. MATERIALS AND METHODS: We queried the Ovid Medline® and PubMed® databases to locate published reports of renal artery pseudoaneurysm after partial nephrectomy. Studies were included in comparative analysis if they were in English and showed the total number of procedures performed and perioperative complications. RESULTS: Included studies represented a total of 5,229 patients, of whom 2,494 and 2,735 underwent open and minimally invasive partial nephrectomy, respectively. A total of 25 and 52 renal artery pseudoaneurysms were reported after open and minimally invasive procedures (weighted 1.00% and 1.96%, respectively). The difference between these 2 values was statistically significant (p ≤ 0.001). Patients diagnosed with renal artery pseudoaneurysm presented a mean of 14.9 days after surgery and 87.3% of them had gross hematuria at presentation. Almost all patients with renal artery pseudoaneurysm were treated with percutaneous angioembolization with 96% success. CONCLUSIONS: Although it is rare, the risk of renal artery pseudoaneurysm after partial nephrectomy is significant and should be high on the differential for a patient who presents postoperatively with gross hematuria. The incidence of renal artery pseudoaneurysm is higher after minimally invasive partial nephrectomy than after an open approach. Angioembolization for renal artery pseudoaneurysm after partial nephrectomy offers an excellent success rate and minimal patient morbidity.

Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.

PURPOSE: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. MATERIALS AND METHODS: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. RESULTS: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. CONCLUSIONS: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

A rare presentation of nephrogenic adenoma: multiple upper tract lesions in a female patient.

Nephrogenic adenomas are rare benign lesions of the urinary tract occurring most frequently in the bladder of male patients. We report the case of a female patient presenting with gross hematuria, which lateralized to the left ureter on cystoscopy. At the time of ureteroscopy, two polypoid lesions were identified in an upper and lower pole calyx, which were found on biopsy to be nephrogenic adenomas. In addition to reporting this case, we review the literature for the pathophysiology of nephrogenic adenomas.

Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVES: To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. METHODS: We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012-03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P <.05 was considered significant. RESULTS: Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023). CONCLUSIONS: Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

Diagnosis and surgical management for primary hyperaldosteronism.

The evaluation of primary hyperaldosteronism presents a challenge to endocrinologists, radiologists, and urologic surgeons. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential in order to assess the nature and function of hypersecreting adrenal glands. Furthermore, it is of great importance to identify individuals that are morbidly affected by aldosterone hypersecretion. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Herein we describe the evaluation and surgical management for patients with a suspected diagnosis of primary hyperaldosteronism.

Bioregenerative Umbilical Cord Amniotic Membrane Allograft Ureteral Wrap During Robot-Assisted Ureterolysis.

Omental wrap is commonly performed after ureterolysis to prevent ureteral obstruction from recurrence of periureteral adhesions and fibrosis. We present the case of a 37-year-old Caucasian woman with a history of two cesarean sections and laparotomy for the treatment of endometriosis. She subsequently developed right flank pain caused by a right distal ureteral stricture requiring a chronic indwelling ureteral stent. Diagnostic laparoscopy revealed extrinsic compression of the ureter for which robot-assisted ureterolysis was performed. Because of inadequate omentum, we report the initial use of a cryopreserved bioregenerative umbilical cord amniotic membrane allograft to perform a ureteral wrap to promote ureteral tissue healing and serve as an adhesion barrier to prevent recurrence of the fibrosis.

Primary renal embryonal rhabdomyosarcoma in an adult patient.

Adult renal rhabdomyosarcoma (RMS) is a rare and aggressive entity with a paucity of data and reports in the literature. As a result, treatment guidelines for this malignancy are not well-established. Herein, we present the diagnosis, management and clinical course of a 39-year-old patient diagnosed with primary renal embryonal RMS (ERMS) following radical nephrectomy. We also review the existing literature on primary renal ERMS.

Single port robotic assisted reconstructive urologic surgery-with the da Vinci SP surgical system.

BACKGROUND: Single port (SP) robotic assisted laparoscopic surgery was approved by the FDA for urologic surgery and clinically available in 2018. This new robotic system enables a camera and 3 separate instruments, with fully wristed motions, to be placed through a single 25 mm port. This system was designed to perform complex surgery in narrow deep spaces making it very suitable for complex urinary tract reconstruction surgery. This paper will describe our early experience of using the SP system for several types of urinary reconstruction procedures and will present our lessons learned, surgical philosophy to using the SP and early data. As with all new technologies, there is an associated learning curve and nuances to be discovered and overcome. METHODS: The da Vinici SP™ surgical system was acquired and delivered to at our institution in January 2019. Five high volume robotic urologic surgeons at our institutions underwent certification with the da Vinci SP™ and have been adding this technology into their armamentarium. Almost all cases were recorded for quality improvement initiatives and evaluated with the goal of creating standard operating procedures in terms of access, steps of procedure and minimizing pit falls. Data from all patients undergoing SP urinary tract reconstruction that were entered into our prospective institutional database were reported. RESULTS: From 1/2019 to 8/2019 we have performed 71 urologic SP cases with the SP of which 18 were for urinary tract reconstructive procedures. These cases included 15 pyeloplasties, 1 buccal mucosa ureteroplasty, 1 ureteral implant and 1 repair of vesico-vaginal fistula. This paper outlines our standard operating procedures for table positioning, port placement, access and surgical steps for these complex SP cases. Our early data suggests that use of the SP system for urinary reconstruction is safe and reproducible. CONCLUSIONS: The SP robotic surgical system has the potential to be used for nearly all robotic urologic reconstructive procedures. Advantages include a superior cosmetic result and ability to access all surgical quadrants without re-docking or repositioning. Limitations include no near infrared fluorescence imaging, smaller working space and slightly increased difficulty with retraction. We believe these obstacles will be overcome with time and experience. The da Vinci SP™ surgical system, in our initial experience, appears to be as safe and effective as its multiport counterpart for reconstructive surgeries.

Postoperative Complications After Robotic Partial Nephrectomy.

Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as ≥IIIa: 8/13 (61.5%) vs 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p < 0.05). No significant predictors for AM were identified. Conclusions: The incidence of postoperative complications after RPN remains low (5.3% vs 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs 0%, 3.1% vs 1.1%).

Multi-institutional Experience Comparing Outcomes of Adult Patients Undergoing Secondary Versus Primary Robotic Pyeloplasty.

OBJECTIVE: To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS: We retrospectively reviewed our multi-institutional, collaborative of reconstructive robotic ureteral surgery (CORRUS) database for all consecutive patients who underwent RP between April 2012 and September 2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; P < .05 was considered significant. RESULTS: Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 vs 50.0 milliliters, respectively; P < .01) and longer operative time (188.0 vs 136.0 minutes, respectively; P = .02). There was no difference in major (Clavien >2) complications (P = .29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% vs 92.3%, respectively; P = .44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% vs 0.0%, respectively, P < .01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% vs 40.8%, respectively; P < .01) for secondary vs primary repair. CONCLUSION: Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.

Minimally invasive surgical management of pelvic-ureteric junction obstruction: update on the current status of robotic-assisted pyeloplasty.

BACKGROUND: Pelvi-ureteric junction (PUJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Historically, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The advent of laparoscopy and robotic-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. AIMS We review the current status of robotic-assisted laparoscopic pyeloplasty and report on the result, continuing evolution, and potential role for this surgical procedure. MATERIALS AND METHODS: A review of the recent literature encompassing laparoscopic and robotic-assisted pyeloplasty was conducted with particular attention to operative techniques, surgical outcomes, and complication rates. RESULTS: Laparoscopic and robotic-assisted approaches are able to duplicate the open technique, and not surprisingly, are now being shown to be as efficacious as the gold standard open approach. The laparoscopic remains technically challenging due to the high proficiency level required for intracorporeal suturing, although added experience has resulted in shorter operative times. The advent of robotics has further expanded the breadth of this reconstructive procedure while preserving the benefits of decreased pain, shorter hospitalization, rapid convalescence, and an improved cosmetic result. DISCUSSION: The introduction of robotics to the field of minimally invasive surgery facilitates this procedure and may allow for more widespread implementation by surgeons of varying skill levels. These benefits must be balanced against the increased costs of the robotic platform. CONCLUSION: Clinical reports have demonstrated that robotic-assisted pyeloplasty is a safe, feasible, and effective technique for treating ureteropelvic junction obstruction in short term studies. Additional studies with prolonged follow-up will ultimately provide valuable information as to the long-term efficacy of robotic-assisted laparoscopic pyeloplasty.

Quality of life of men treated for localized prostate cancer: outcomes at 6 and 12 months.

GOALS OF WORK: Treatments for early-stage prostate cancer (PCa) are highly effective; therefore, research studies that explore quality of life (QOL) issues associated with different treatments are important. The purposes of this study were to (a) examine differences among treatment groups of men treated with either radiation therapies or radical prostatectomy for PCa and (b) examine quality of life outcomes over time. PATIENTS AND METHODS: We report outcomes 6 and 12 months after 159 men began treatment for PCa with either one of two types of radiation treatment (intensity-modulated radiation therapy plus high dose rate or intensity-modulated radiation therapy plus seed implantation) or radical prostatectomy. MAIN RESULTS: Significant differences among groups are described. Significant predictors of QOL at 6 months included urinary, bowel, and sexual symptoms, anxiety, depression, problem-focused coping, and physiological self-efficacy. Significant predictors of QOL at 12 months were urinary and bowel symptoms, stress, depression, problem-focused coping, and physiological self-efficacy. Demographic variables, race, and living status were significant predictors of quality of life at 12 months. CONCLUSIONS: Physiological symptoms and psychological symptoms were both significant predictors of QOL. The psychological factors that predicted quality of life in this study have potential for intervention and point to the next stage of the research.

Surgical management of metastases to the adrenal gland: open, laparoscopic, and ablative approaches.

The adrenal gland is a potential site of metastasis for various malignancies. Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adenomas. Differentiation of a metastatic lesion from a primary adrenal lesion can be challenging and requires the selective use of radiologic imaging, serologic testing, and adrenal biopsy. In patients who present with an isolated adrenal metastasis, adrenalectomy is often considered to aid in cancer control. Numerous studies have reported improved survival with resection of solitary adrenal metastases for various types of primary tumors. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Proper patient selection for the laparoscopic versus open approach remains paramount in deciding the best treatment for the individual patient.

Vascular anomalies during laparoscopic renal surgery: incidence and management of left-sided inferior vena cava.

BACKGROUND: Left-sided inferior vena cava (IVC) is an unusual abnormality that may be clinically significant during renal surgery. METHODS: We report the unique case of a patient with a centrally located left renal mass who underwent laparoscopic radical nephrectomy. During the hilar dissection, unusual vascular anatomy was encountered. The patient was noted to have a left-sided inferior vena cava with multiple renal veins and anomalous tributaries. Laparoscopic radical nephrectomy was performed without complication. DISCUSSION: The embryology of a left-sided inferior vena cava is reviewed, and the safety and feasibility of a laparoscopic approach is discussed.

Adrenal-preserving minimally invasive surgery: update on the current status of laparoscopic partial adrenalectomy.

Adrenalectomy is the standard of care for hormonally active adrenal masses. In recent years, minimally invasive laparoscopic excision has become a preferred management option. As with advances in parenchymal-sparing renal surgery, investigators have begun to examine adrenal-sparing procedures to preserve functional adrenal tissue. This article reviews the recent literature and reports on intermediate results with laparoscopic partial adrenalectomy (LPA).