Clinical Research Office of the Endourological Society Global GreenLight Laser Study: Outcomes from a contemporary series of 713 patients.

OBJECTIVE: To evaluate the outcome in patients undergoing photoselective vaporization of the prostate for benign prostatic obstruction as part of the Clinical Research Office of the Endourological Society Global GreenLight Laser Study. METHODS: Data were collected on 713 patients with lower urinary tract symptoms suggestive of benign prostatic obstruction undergoing photoselective vaporization of the prostate at 25 centers worldwide, between April 2010 and April 2012. Three types of GreenLight laser powers were used: 80 W, 120 W or 180 W. Intraoperative and postoperative complications were recorded. Outcome parameters measured at baseline, 6-12 weeks, 6 months and 12 months were: uroflow measurements, International Prostate Symptom Score; prostate-specific antigen and International Index of Erectile Function. RESULTS: Operating time was shortest with the 180-W laser at 53.8 min. Intraoperatively, bleeding occurred in 3.1% of patients. Statistically significant changes were reported in maximum flow rate, postvoid residual urine, International Prostate Symptom Score, quality of life score and prostate-specific antigen (P < 0.01) at each time-point assessed for the 80- and 120-W lasers as well as for the 180-W laser, with the exception of prostate-specific antigen at 6 months and 12 months. There were 14 Clavien-Dindo grade III-A complications and two grade III-B. The incontinence rate at 12 months was 6.3%, 4.5%, and 2.6% for the 80, 120 and 180 W lasers, respectively. The overall blood transfusion rate was 0.4%. CONCLUSIONS: Objective and subjective improvement after GreenLight laser treatment worldwide was significant at 1-year follow up. Morbidity and complications were low. Although not a randomized control study, the data can provide an indication of the outcome of the different GreenLight laser powers.

Continence outcomes after bladder neck preservation during robot-assisted laparoscopic prostatectomy (RALP).

PURPOSE: Urinary incontinence is one of the major prostate cancer treatment-related morbidities. We review our initial robot-assisted laparoscopic prostatectomy (RALP) experience, focusing on post-surgery continence rates. MATERIAL AND METHODS: Two-hundred and thirty-three consecutive patients were identified from a prospectively maintained RALP database. A bladder neck sparing dissection was preferentially performed during transperitoneal RALP. On postoperative day 5 or 6 (clinic logistics), the urethral catheter was removed following a normal cystogram. RESULTS: Median operative time was 190 minutes and estimated blood loss was 75 mL. Three (1.3%) patients required bladder neck reconstruction, while 198 (85.0%) had bilateral, 20 (8.6%) had unilateral and 15 (6.4%) did not undergo nerve sparing prostatectomy. One-hundred and ninety-nine (85.4%) patients had negative surgical margins. Median hospitalization and urethral catheter duration were 1.0 and 5.0 days, respectively. At six weeks, a median 1.0 pad per day usage was reported and mean AUASS and QoL were significantly improved from baseline (p < 0.05). Of the 220 patients having a minimum three-month follow-up, 152 (69.1%) achieved urinary continence without pads. Age, AUASS, QoL, prostate volume and prior TUR surgery independently had significant impact on early continence rate (p < 0.05). CONCLUSION: A bladder neck sparing dissection allows for early return of urinary continence following RALP without compromising cancer control.

Does prostate configuration affect the efficacy and safety of GreenLight HPS™ laser photoselective vaporization prostatectomy (PVP)?

We evaluate the efficacy and safety of GreenLight HPS™ laser photoselective vaporization prostatectomy (PVP) for the treatment of benign prostatic hyperplasia (BPH) with different prostate configuration. Patients were stratified into two groups: bilobe (group I) and trilobe (group II) BPH. Transurethral PVP was performed using a 120 W GreenLight HPS™ side-firing laser system. American Urological Association Symptom Score (AUASS), Quality of Life (QoL) score, maximum flow rate (Q max), and postvoid residual (PVR) were measured preoperatively and at 1 and 4 weeks and 3, 6, 12, 18, 24 and 36 months postoperatively. A number of 160 consecutive patients were identified (I: 86, II: 74). Among the preoperative parameters, there were significant differences (p < 0.05) in prostate volume (I: 46.0 ± 19.8; II: 87.5 ± 39.6 ml), Q max (I: 9.9 ± 3.9; II: 8.7 ± 3.5 ml/sec), PVR (I: 59.2 ± 124.6; II: 97.7 ± 119.1 ml) and PSA (I: 1.4 ± 1.4; II: 3.6 ± 2.6 ng/ml), while AUASS and QoL were similar (p > 0.05). Significant differences (p < 0.05) in laser utilization (I: 9.5 ± 6.6; II: 19.5 ± 11.6 min) and energy usage (I: 63.1 ± 43.9; II: 132.5 ± 81.1 kJ) were noted. Clinical outcomes (AUASS, QoL, Q max, and PVR) showed immediate and stable improvement from baseline (p < 0.05) within each group, but no significant differences between the two groups were observed during the follow-up period (p > 0.05). The incidences of adverse events were low and similar in both groups. Our experience suggests that BPH configuration has little effect on the efficacy and safety of GreenLight HPS™ laser PVP.

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.

Does age affect the efficacy and safety of GreenLight HPS™ laser photoselective vaporization prostatectomy?

BACKGROUND: To evaluate the efficacy and safety of GreenLight HPS(™) (High Performance System) laser photoselective vaporization prostatectomy (PVP) for the treatment of benign prostatic hyperplasia (BPH) in patients of different age groups. METHODS: 164 consecutive patients were stratified into two groups: age <70 (group I, n = 93) and age ≥70 (group II, n = 71) years. Transurethral PVP was performed using a GreenLight HPS™ side-firing laser system. Voiding parameters were measured preoperatively and at 1 and 4 weeks and 3, 6, 12, 18, 24 and 36 months postoperatively. RESULTS: Among the preoperative parameters evaluated, there were significant differences (p < 0.05) in prostate volume (I: 58.7; II: 73.6 mL) and serum prostate-specific antigen (I: 1.9; II: 2.9 ng/mL), while American Urological Association Symptom Score (AUASS), Quality of Life (QoL), maximum flow rate (Qmax), Sexual Health Inventory for Men (SHIM) and post void residual (PVR) were similar (p > 0.05) between groups. No significant differences in laser utilization, energy usage and operating time were noted. Clinical outcomes (AUASS, QoL, Qmax, PVR) showed immediate and stable improvement from baseline (p < 0.05) within each group, but no significant differences between the two groups were observed during the follow-up period. The incidence of adverse events was low and similar in both groups. CONCLUSIONS: The results suggest that age has little effect on the efficacy and safety of GreenLight HPS™ laser PVP.

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff and isthmusectomy in a horseshoe kidney for invasive urothelial carcinoma of the renal pelvis.

Upper tract invasive urothelial carcinoma and horseshoe kidneys are familiar to the practicing urologist but relatively rare individual entities. The complication of managing them when they coexist in the same patient can be challenging. Herein, we present the first reported case in which an upper tract invasive urothelial carcinoma in a horseshoe kidney was successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff. This highlights the fact that complex anatomy can be managed in a completely minimally invasive fashion, and sound oncologic principles can still be maintained.

Laser surgery simulation platform: toward full-procedure training and rehearsal for benign prostatic hyperplasia (BPH) therapy.

Recently, photo-selective vaporization of the prostate (PVP) has been a popular alternative to the standard electrocautery - transurethral resection of prostate (TURP). Here we introduce a new training system for practicing the laser therapy by using a virtual reality (VR) simulator. To interactively and realistically simulate PVP on a virtual organ with an order of a quarter million elements, a few novel and practical solutions have been applied to handle the challenges in modeling tissue ablation, contact/collision and deformation; endoscopic instruments tracking, haptic rendering and a web/database curriculum management module are integrated into the system. Over 40 urologists and surgical experts have been invited nationally and participated in the system verification.

Effects of the School-Based Integrated Health Promotion Program With Hydroponic Planting on Green Space Use and Satisfaction, Dietary Habits, and Mental Health in Early Adolescent Students: A Feasibility Quasi-Experiment.

Background: School-based green space activities have been found to be beneficial to the physical activity level and lifestyle habits of adolescent students. However, their effects on green space use and satisfaction, mental health, and dietary behaviors required further investigation. This study aimed to investigate the effects of school-based hydroponic planting integrated with health promotion activities in improving green space use, competence and satisfaction, healthy lifestyle, mental health, and health-related quality of life (QoL) among early adolescent students in secondary schools. Methods: This study adopted a three-group comparison design (one control and two intervention groups). Secondary school students (N = 553) of grades 7-9 participated in either (1) hydroponic planting (two times per week for 8 months) integrated with health promotion activities; (2) only health promotion activities (one time per week for 6 weeks); or (3) control group. Outcomes assessed by questionnaire included green space use and satisfaction, life happiness, lifestyle, depressive symptoms, and health-related QoL. Results: After adjusting for sex and school grade, the scores in "green space distance and use" and "green space activity and competence" were significantly better in the intervention groups than in the control group. Hydroponic planting integrated with health promotion activities was also associated with better scores in dietary habits and resistance to substance use. Intervention groups had a higher score in "Green space sense and satisfaction" and life happiness when compared with the control group. Conclusions: Our study shows that the school-based hydroponic planting integrated with health promotion activities were feasible and, to a certain extent, useful to improve green space use and competence, dietary habits, and resistance to substance use among early adolescent students in secondary schools in urban areas. Future studies should address the limitations identified, for example, designing a randomized controlled trial that could fit school schedules to generate new evidence for physical and mental health in adolescent communities.

Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS: Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS: The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Catheter-free 120W lithium triborate (LBO) laser photoselective vaporization prostatectomy (PVP) for benign prostatic hyperplasia (BPH).

INTRODUCTION AND OBJECTIVE: We evaluate the safety and efficacy of catheter-free LBO laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). METHODS: We prospectively evaluated our initial LBO laser PVP experience and the need for urethral catheterization. RESULTS: Seventy consecutive patients were identified. 49 (70%) were discharged without (C-) and 21 (30%) were discharged with (C+) a urethral catheter. There were no significant differences in pre-operative parameters, including age (C-: 65+/-10 vs. C+: 69+/-9 years), AUASS (C-: 22+/-6 vs. C+: 21+/-6), Qmax (C-: 10+/-4 vs. C+: 8+/-3 ml/second), PVR (C-: 62+/-105 vs. C+: 57+/-82 ml) and prostate volume (C-: 65+/-35 vs. C+: 86+/-53 ml). There were no significant differences in laser time and energy usage. AUASS, Qmax and PVR values showed significant improvement within each group (P<0.05), but there were no significant differences between the two groups. All were outpatient procedures. 2/70 (2.9%) patients required catheter reinsertion in C+. The overall incidence of adverse events was low and did not differ between the two groups. CONCLUSIONS: Our experience suggests that catheter-free LBO laser PVP is safe and effective for the treatment of LUTS secondary to BPH.

High-power potassium-titanyl-phosphate or lithium triboride laser photoselective vaporization prostatectomy for benign prostatic hyperplasia: a systematic approach.

BACKGROUND AND PURPOSE: We describe a safe and reproducible technique for potassium-titanyl-phosphate (KTP) and lithium triboride (LBO) laser photoselective vaporization prostatectomy (PVP). TECHNIQUE: With the patient under anesthesia in the dorsal lithotomy position, cystoscopy is performed. Using a high-power KTP/LBO laser system, a groove is created along the lateral-median lobe junction from the bladder neck to the verumontanum to delineate the margins of vaporization. The remainder of the ipsilateral lobe is vaporized using a series of overlapping passes along the length of the groove. The contralateral lobe is vaporized in a similar manner. Finally, the median lobe is vaporized from lateral to medial. A 20F urethral catheter is placed at the conclusion of the procedure. RESULTS: This technique has been successful in 240 consecutive patients over an 18-month period. CONCLUSION: This systematic approach has been safe, effective, and reproducible for KTP/LBO laser PVP. It has become our standard technique for this procedure.

Case report: hand-assisted laparoscopic radical heminephrectomy for renal-cell carcinoma in a horseshoe kidney.

A 63-year-old woman with an incidentally detected 10-cm enhancing renal mass in the left moiety of a horseshoe kidney was treated with a transperitoneal hand-assisted laparoscopic (HAL) radical heminephrectomy. The operative time was 273 minutes, and estimated blood loss was 250 mL. To our knowledge, this is the initial case of HAL radical heminephrectomy for renal-cell carcinoma in a horseshoe kidney. Appropriate pre-operative imaging and surgical technique for the isthmusectomy are highlighted.

Percutaneous cystolithotomy of large urinary-diversion calculi using a combination of laparoscopic and endourologic techniques.

BACKGROUND AND PURPOSE: Patients with urinary diversions are at higher risk for bladder urolithiasis. Often, the stone burden is large, necessitating open stone removal. We describe our technique for removing such stones using a combination of laparoscopic and endourologic instrumentation. PATIENTS AND METHODS: With the patient in the dorsal lithotomy position or supine, cystoscopy is performed via the native urethra or catheterizable stoma, respectively. With the urinary reservoir distended with normal saline, percutaneous access is obtained under direct vision with a 10-mm trocar introduced through the scar of the previous suprapubic cystostomy. A laparoscopic entrapment bag is introduced through the trocar, into which the calculi are manipulated. The bag is delivered percutaneously through the trocar site with subsequent removal of the trocar. A 30F Amplatz renal dilator sheath (Cook Urological, Spencer, IN) is introduced directly into the bag. An ultrasonic lithotrite passed through a nephroscope is utilized to fragment and evacuate the calculi. Closure of the neocystotomy is not performed. A drainage catheter is left in for 7 days. RESULTS: This procedure has been successful in eight consecutive patients, six with bladder augmentations, one with a bladder reconstruction with appendicovesicostomy, and one with an Indiana pouch. All calculi were radiopaque, having a mean linear size of 4.1 cm (range 1.5-7.0) cm. Several patients had multiple stones. The mean operating room time was 123 minutes (range 48-228 minutes). Two patients had concomitant ureteroscopy with laser lithotripsy for ureteral calculi. All were rendered stone free with one procedure and were discharged within 23 hours after surgery. There were no immediate or delayed complications. CONCLUSIONS: Our technique of percutaneous cystolithotomy utilizing laparoscopic and endourologic instrumentation is safe and effective for the removal of large calculi from urinary diversions. It is well tolerated, allows complete stone removal in a single sitting, and obviates an open procedure.

Pediatric laparoscopic pyeloplasty: 4-year experience.

BACKGROUND AND OBJECTIVE: Laparoscopic dismembered pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in the pediatric population is comparable to open dismembered pyeloplasty in success rates. Experience with this procedure however remains limited. We review our experience with this technique. PATIENTS AND METHODS: The hospital records of consecutive patients undergoing surgery for UPJO between May 2001 and May 2005 were reviewed. Only those who underwent laparoscopic pyeloplasty for single system UPJO were included in the study. Indications for surgical correction were T(1/2) > or = 20 minutes by diethylene triamine pentaacetic acid Lasix renography or symptomatology with hydronephrosis seen on renal ultrasonography (US). RESULTS: Fifty-nine patients were identified, all of whom were treated surgically for salvageable UPJO. Four underwent percutaneous endopyelotomy for concomitant urolithiasis, 27 underwent open dismembered pyeloplasty (parent choice or under 18 months of age), and 28 underwent laparoscopic dismembered pyeloplasty. One patient had bilateral laparoscopic repairs at different times, resulting in 29 renal units that were reconstructed laparoscopically. Of these, 28 were completed. Eighteen procedures were performed on boys and 11 on girls. The mean age was 8.1 (1.6-18.9) years. The mean operating room time was 255 (157-396) minutes. Estimated blood loss was <10 mL in every patient. One patient required hospitalization longer than 23 hours because of postoperative ileus. A retroperitoneal urinoma developed in another patient, despite having a ureteral stent; it resolved with urethral catheter drainage. The first laparoscopic pyeloplasty resulted in open conversion because of failure of progression of the ureteropelvic anastomosis. At a mean follow-up of 27.9 (7.6-58.0) months, all patients demonstrated improvement of symptoms and drainage on nuclear renography or a decrease in the grade of hydronephrosis on renal US. CONCLUSION: Our series of patients undergoing laparoscopic pyeloplasty had excellent results with low morbidity. We consider this our primary technique for surgical correction of UPJO in patients older than 18 months.

Tumor recurrence incidence following hand-assisted laparoscopic nephroureterectomy.

BACKGROUND AND OBJECTIVES: We evaluated the incidence of tumor recurrence following hand-assisted laparoscopic nephroureterectomy (HALNU) for the treatment of upper tract urothelial carcinoma. METHODS: The medical records of consecutive patients who underwent HALNU by a single surgeon (CW) between October 2001 and May 2005 were reviewed. The ureter was clipped before kidney dissection to prevent distal migration of tumor. Following liberation of the kidney, the bladder cuff and intramural ureter were excised by using a Collings knife under cystoscopic guidance. RESULTS: Ten patients were identified. The primary location of disease was confined to the intrarenal collecting system. Eight high-grade (HG) and 2 low-grade (LG) tumors were removed, with pT3 (6), pT2 (1), pT1 (1), and pTa (2) disease. The patient having a LG pTa urothelial carcinoma developed pulmonary metastasis 20 months following surgery and survived an additional 26 months. Two patients, each having a HG pT3 tumor, developed a urothelial carcinoma in the bladder contralateral to the site of ureteral excision. At a mean follow-up of 41 months, there has been no evidence of tumor recurrence in the pelvis. CONCLUSION: Our technique of HALNU does not appear to harbor an increased risk for urothelial carcinoma recurrence.

Risks and Benefits of Postoperative Double-J Stent Placement After Ureteroscopy: Results from the Clinical Research Office of Endourological Society Ureteroscopy Global Study.

PURPOSE: Double-J stent placement after stone removal by ureteroscopy (URS) is common and recommended in many cases but debatable in others. In this study, the risks and benefits of postoperative Double-J stent placement in URS stone treatment procedures undertaken in current clinical practice are examined. MATERIALS AND METHODS: The Clinical Research Office of Endourological Society (CROES) URS is a prospective, observational, international multicenter study, in which patients are candidates for URS as primary treatment or after failure of prior treatment for ureteral and renal stones. Baseline, intraoperative, and postoperative data were collected. Predictors and outcomes of postoperative stent placement were analyzed by inverse probability-weighted regression adjustment of the relationship between a Double-J stent placement and outcomes (complications, readmission [including retreatment], and length of hospital stay). RESULTS: Significant predictors of postoperative Double-J stent placement in URS treatment of ureteral stones were intraoperative complications, impacted stones, operation time, stone burden, age, presence of a solitary kidney, and stone-free rate. In renal stone treatment, the predictors identified included operation time, age, preoperative stent placement, anticoagulant use, presence of a solitary kidney, and intraoperative complications. In both ureteral and renal stone treatment groups, postoperative placement of a Double-J stent resulted in significantly fewer postoperative complications (p < 0.001) compared with patients who did not receive a stent. CONCLUSIONS: Patient- and procedure-related variables were identified, which may enable an individualized approach to postoperative stenting, resulting in improved clinical outcomes in urologic stone treatment by URS.

Laparoscopic transabdominal transvesical vesicovaginal fistula repair.

BACKGROUND AND PURPOSE: Transabdominal transvesical repair has been the standard treatment for difficult vesicovaginal fistulae. We describe a laparoscopic transvesical technique that minimizes operative morbidity while adhering to the principles of transabdominal repair as described by O'Conner. TECHNIQUE: The patient is placed in the lithotomy position using Allen stirrups, and bilateral 5F open-ended ureteral catheters are placed cystoscopically. Using four laparoscopic ports, the prevesical space is accessed. The bladder is bivalved down to the fistula, and stay sutures are placed at the bladder edges for exposure. The fistulous tract and adjacent fibrotic tissue are excised, and the bladder and vagina are closed separately with single layers of full-thickness interrupted 2-0 Vicryl sutures. An omental flap is interposed between suture lines in the bladder and vagina. The ureteral catheters are sequentially removed on the first and second postoperative days. A gravity cystogram is performed 3 weeks postoperatively; if it is normal, the urethral catheter is removed. RESULTS: This procedure has been performed on two consecutive patients who had failed prior Latzko repairs. Both patients were discharged 2 days postoperatively without complications. At a follow-up of 41 months in the first patient and 39 months in the second, no fistula recurrence has been seen. CONCLUSIONS: Laparoscopic transvesical vesicovaginal fistula repair appears to be a safe and effective procedure that adheres to the principles of a transabdominal transvesical fistula repair while decreasing morbidity and improving cosmesis. Continued follow-up is required to determine its long-term efficacy compared with the accepted open transabdominal and transvaginal approaches.

Right-sided intrarenal splenosis mimicking a renal carcinoma.

We describe a patient who underwent nephrectomy for an enhancing right renal mass that was subsequently pathologically confirmed as right renal splenosis. Since renal splenosis is quite rare and has previously been reported only in the left kidney, we did not consider splenosis in our differential diagnosis during the evaluation of the renal mass. Magnetic resonance imaging, as well as radionucleotide scan using 99mTc-labelled red blood cells, has been utilized for identifying ectopic splenic tissue. An elevated index of suspicion must be present in patients with a history of splenectomy or traumatic splenic rupture to avoid undue nephrectomy.

Two trocar laparoscopic varicocelectomy: approach and outcomes.

BACKGROUND AND OBJECTIVES: The surgical indications and proper management of varicoceles in the pediatric population continue to be controversial. Historically, open surgical approaches have had recurrence rates between 2% to 6% and a low rate of complications. We present a modified laparoscopic technique for the treatment of clinically significant varicoceles. METHODS: Consecutive pediatric patients presenting with clinically significant varicoceles between May 2000 and July 2003 were considered for laparoscopic varicocelectomy. A 5-mm 2-port laparoscopic varicocelectomy was performed, with supraumbilical and contralateral lower quadrant placement of the trocars. The Harmonic scalpel was used to fulgurate the spermatic vessels in a nonartery sparing technique. RESULTS: Ten clinically significant varicoceles were identified in 9 patients, all of which were ligated with this technique. One patient was treated for bilateral varicoceles. Average operating room time was 53 minutes (range, 45 to 65). All patients were discharged from the ambulatory surgery unit and returned to their regular physical activity within 2 weeks after surgery. Upon clinical reevaluation 6 weeks post surgery, there was no evidence of varicocele recurrence or hydrocele formation, and all patients were asymptomatic. CONCLUSIONS: Our 2-port laparoscopic varicocelectomy is comparable to traditional open surgical approaches in recurrence and complication rates. This laparoscopic repair may be superior to open techniques in operating time, convalescence, and cosmesis. The procedure is easily mastered and does not require microsurgical skills.

Screening and identification of differentially expressed transcripts in circulating cells of prostate cancer patients using suppression subtractive hybridization.

BACKGROUND: Tumor metastasis and changes in host immunosurveillance are important components in cancer development. Tumor cell invasion into the bloodstream is an essential step for systemic metastasis. Currently, the detection of tumor cells in the circulation is mainly dependent upon the utilization of known epithelial cell markers. However, expression of these molecules is not limited to cancer patients; healthy people also have a small number of epithelial cells in their circulation. Utilizing these markers to detect circulating tumor cells (CTCs) cannot adequately explain the mechanisms of tumor cell survival or their development of metastatic potential in peripheral blood. The immune system can also evolve along with the cancer, actually promoting or selecting the outgrowth of tumor variants. Unfortunately, both metastasis and immunosurveillance remain mysterious and are debatable because we have yet to define the molecules that participate in these processes. We are interested in identifying the existence of expressed genes, or mRNA species, that are specifically associated with circulating cells of cancer-bearing patients using prostate cancer (PCa) as a model. RESULTS: We established two comprehensive subtracted cDNA libraries using a molecular technique called suppression subtractive hybridization. This technique selectively amplifies transcripts that are specifically expressed in circulating cells of either PCa patients or healthy men. Following sequencing reaction, we showed that 17 out of 23 (73.9%) sequenced clones did not match any mRNAs in the GenBank database. This result suggests that genes associated with alterations in circulating cells of cancer-bearing patients are largely unknown. Semi-quantitative RT-PCR confirmed that two genes are up-regulated in circulating cells of PCa patients, whereas another two genes are down-regulated in the same patients. CONCLUSION: The comprehensive gene expression analysis is capable of identifying differentially expressed genes in circulating cells of healthy men and PCa patients. We did not attempt to enrich specific cell types in this study because phenotypes of CTCs and subsets of leukocytes participating in immunosurveillance remain largely unknown. Continuous studies of these differentially expressed genes will eventually lead us to understand the mechanisms involved in tumor metastasis and immune modulation during cancer development.