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.

Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center.

PURPOSE: We assessed the long-term efficacy, complications and patient perceptions of microsurgical denervation of the spermatic cord in the treatment of chronic orchialgia. MATERIALS AND METHODS: Microsurgical denervation of the spermatic cord was performed on 95 testicular units in 79 men (mean age 40.3 years, mean duration of pain 62 months, 16 bilateral) for chronic orchialgia. Conservative management failed in all, and patients were evaluated with an extensive medical history and physical examination. To be a candidate for microsurgical denervation of the spermatic cord each man would have responded either completely or partially to spermatic cord block (greater than 50% decrease in pain) and had no identifiable reversible etiology. Postoperative pain rating scales (0 to 10) were used to determine efficacy. RESULTS: Mean followup was 20.3 months (range 1 to 102 months) and complete, durable relief was noted in 67 (71%) testicular units, partial relief in 17 (17%), and unchanged in 11 (12%). No patients reported worse pain. Complications included testicular atrophy without hypogonadism in 2 patients, superficial wound infection in 2, hydrocele in 2 and an incisional hematoma in 1. CONCLUSIONS: Microsurgical denervation of the spermatic cord is a minimally invasive, effective and durable management option for treatment of chronic orchialgia refractory to medical management, preserving the physiological function and psychological role of the testes.

The effects of 5α-reductase inhibition on benign prostatic hyperplasia treated by photoselective vaporization prostatectomy with the 120 Watt GreenLight HPS laser system.

BACKGROUND: We sought to determine whether the efficacy and efficiency of 120W GreenLight HPS (American Medical Systems, Inc) laser photoselective vaporization prostatectomy (PVP) is compromised in patients on chronic 5α-reductase inhibitor (RI) therapy. STUDY DESIGN: Our GreenLight HPS laser PVP experience in patients with and without long-term 5αRI was evaluated. American Urological Association Symptom Score (AUASS), quality of life (QoL) score, maximum urinary flow rate (Qmax), and postvoid residual (PVR) were measured preoperatively and at 1 and 4 weeks and at 3, 6, 12, 18, and 24 months postsurgery. PSA values and transrectal ultrasonography (TRUS) prostate volumes were determined preoperatively and at 3 months postsurgery. RESULTS: Fifty-seven patients were on either dutasteride or finasteride (5αRI+) and 124 were not (5αRI-). Mean prostate volumes were 67.1 ± 35.3 mL and 69.2 ± 41.9 mL (p = 0.646) and mean PSA values were 2.2 ± 2.4 ng/mL and 2.7 ± 2.6 ng/ml (p = 0.289), respectively. There were no significant differences in the parameters of laser use (13.6 ± 9.2 minutes and 13.4 ± 10.4 minutes, p = 0.965) and energy usage (87.1 ± 62.4 kJ and 91.8 ± 69.6 kJ, p = 0.623). The majority of patients were catheter-free at discharge for this wholly outpatient procedure. AUASS, QoL, and Qmax values showed significant improvement within each group (p < 0.05). Compared with baseline, PVR values improved in both groups but did not decrease significantly in 5αRI+ (p > 0.05). There was no significant difference in the degree of improvement between the 2 groups in all parameters (AUASS, QoL, Qmax, PVR, PSA, and TRUS volume). CONCLUSIONS: The efficacy and efficiency of PVP with the GreenLight HPS laser are not negatively affected in patients on chronic 5αRI therapy.

Selective renal parenchymal clamping in robot-assisted laparoscopic partial nephrectomy: a multi-institutional experience.

PURPOSE: We describe our multi-institutional experience using a laparoscopic clamp to induce selective regional ischemia during robot-assisted laparoscopic partial nephrectomy (RALPN) without hilar occlusion. PATIENTS AND METHODS: A retrospective review of Institutional Revew Board-approved databases of patients who underwent selective regional clamping during RALPN at four institutions was performed. RESULTS: In 20 patients who were treated for elective indications, RALPN with parenchymal clamping was successful in 17 (85%). Mean age was 63 years (24-78 y). Median tumor diameter was 2.2 cm (1.1-7.2 cm). Mass location was polar in 13 (76%) and interpolar in 4 (24%). Median R.E.N.A.L. nephrometry score was 6 (4-10). Median overall operative time was 190 minutes (129-309 min), while selective clamp time was 26 minutes (19-52 min). Collecting system repair occurred in 8 (47%) patients. No patients needed a blood transfusion. There was no significant difference in preoperative (median 86 mL/min/1.73 m(2)) and immediate postoperative glomerular filtration rate (GFR) (median 78 mL/min/1.73 m(2), P=0.33) or with the most recent GFR (median 78 mL/min/1.73 m(2), P=0.54) at a mean follow-up of 6.1 months (1.2-11.9 mos). Final pathology determination revealed renal-cell carcinoma in 71% with no positive margins on frozen or final evaluation. In three additional patients who were undergoing RALPN, bleeding because of incomplete distal clamp compression necessitated subsequent central hilar clamping for the completion of the procedure. CONCLUSIONS: In our preliminary multi-institutional experience, regional ischemia using a laparoscopic parenchymal clamp is feasible during RALPN for hemostasis. Careful preoperative selection of patients is needed to determine ideal patient and tumor characteristics. Further comparison studies are necessary to determine the true utility of this technique.

Second prize: Recurrence rates after percutaneous and laparoscopic renal cryoablation of small renal masses: does the approach make a difference?

BACKGROUND AND PURPOSE: As radiologic detection of small renal masses increases, patients are increasingly offered percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares these approaches. PATIENTS AND METHODS: Between September 1998 and May 2010, review of our PRC and TLRC experience was performed. Patients with ≥ 12-month follow-up were included for analysis. Post-treatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered if persistent mass enhancement or interval tumor growth was radiographically evident. Repeated biopsy and re-treatment were recommended in the event of recurrence. RESULTS: Sixty-one patients underwent PRC and 84 patients underwent TLRC. No significant differences were noted with respect to demographic factors. Mean tumor size was 2.7 ± 1.1 cm (PRC) and 2.5 ± 0.8 (TLRC) cm (P = 0.090). Mean follow-up was 31.0 ± 15.9 months (PRC) and 42.3 ± 21.2 (TLRC) months (P = 0.008), with local tumor recurrence noted in 10/61 (16.4%) PRC and 5/84 (5.9%) TLRC (P = 0.042). For PRC, disease-free survival (DFS) and overall survival (OS) were 93.7% and 88.9%, respectively, with four patients having evidence of disease at last follow-up. DFS and OS were 91.7% and 89.3% for TLRC, with seven patients having evidence of disease at last follow-up. DFS (P = 0.654) and OS (P = 0.939) were similar. CONCLUSIONS: In this multicenter study of well-matched cohorts, PRC had higher primary treatment failure rates than TLRC. While no differences were noted between DFS and OS, analysis is limited by intermediate follow-up. Further study is necessary to discern reasons for the higher recurrence rates in PRC and to determine what long-term consequences exist.

Does Greenlight HPS(™) laser photoselective vaporization prostatectomy affect sexual function?

PURPOSE: We evaluate the impact of GreenLight High-Performance System (HPS™) laser photoselective vaporization prostatectomy (PVP) on sexual function after treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: We prospectively evaluated our initial single surgeon experience with GreenLight HPS™ laser PVP. All patients had American Urological Association Symptom Score (AUASS), Sexual Health Inventory for Men (SHIM), maximum flow rate (Qmax), and postvoid residual (PVR) determinations. Transurethral PVP was performed using a 120W GreenLight HPS™ side-firing laser system. AUASS, SHIM, Qmax, and PVR were evaluated 1, 4, 12, 24, and 52 weeks postsurgery. Wilcoxon signed rank test and the Student t-test were used to assess the changes from baseline. RESULTS: Seventy-two patients completed 52 weeks of follow-up, having a median age of 69 (45-89) years. The median prostate volume was 62 (21-263) mL. Median AUASS improved significantly from 23 to 8, 6, 5, 5, and 4 (P < 0.05) at 1, 4, 12, 24, and 52 weeks, respectively. Median SHIM changed from 15 to 12, 16, 19, 16, and 17 during the follow-up period (P = 0.032, 0.427, 0.074, 0.081, and 0.259). Minimum change (0 ± 5) in SHIM occurred in 85.5%, 90.5%, 78.8%, 77.5%, and 73.7% of patients; 11.3%, 6.3%, 6.0%, 4.8%, and 7.0% of patients had deterioration of erectile function (SHIM reduction >5); and 3.2%, 3.2%, 15.2%, 17.7%, and 19.3% of patients had improvement of erectile function (SHIM increase >5). Incidence of new-onset retrograde ejaculation was 30%. CONCLUSION: GreenLight HPS™ laser PVP appears to not have a detrimental effect on erectile function.

Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome.

PURPOSE: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success. MATERIALS AND METHODS: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications. RESULTS: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee. CONCLUSIONS: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.