Suture versus staple ligation of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot-assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation. PATIENTS AND METHODS: In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation. RESULTS: Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow-up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6). CONCLUSIONS: In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss.

Rectal Hem-o-Lok clip migration after robot-assisted laparoscopic radical prostatectomy.

INTRODUCTION: Weck Hem-o-Lok clip migration into the bladder has been reported after robot-assisted laparoscopic radical prostatectomy (RALP). We report a case of Weck clip migration into the rectum presenting as a mass on colonoscopy. METHODS: A 61-year-old male with a prostate specific antigen level of 4.84 ng/ml underwent transrectal ultrasound guided biopsy of the prostate revealing a Gleason's 3 + 3 adenocarcinoma of the prostate involving 20% of the sampled tissue for the left apex. He was subsequently treated with a transperitoneal robot-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy. Weck Hem-o-Lok clips were used to ligate the prostate vascular pedicles. The vesicourethral anastomosis was performed using a double armed running technique. RESULTS: Final pathology demonstrated a Gleason 4 + 3 pT2cN0Mx adenocarcinoma of the prostate with negative margins. Four lymph nodes were negative for malignancy. No intraoperative complications occurred. Postoperatively, patient was found to have a Weck Hem-o-Lok clip that migrated into his rectum. This was found on colonoscopy performed for diverticular disease of the colon. The clip was removed without complication. CONCLUSIONS: Judicious use of Weck clips during RALP and communication with physicians participating in patient care for those who have undergone RALP is crucial in minimizing complications and avoiding subsequent procedures.

Radiofrequency ablation-assisted robotic laparoscopic partial nephrectomy without renal hilar vessel clamping versus laparoscopic partial nephrectomy: a comparison of perioperative outcomes.

OBJECTIVES: Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy (LPN) may allow for improved hemostasis without need for renal hilar vessel clamping and elimination of warm ischemia to the kidney. We compare outcomes in patients undergoing radiofrequency ablation-assisted robotic clampless partial nephrectomy (RF-RCPN) and LPN. METHODS: Thirty-six patients and 42 patients underwent LPN and RF-RCPN, respectively. In the RF-RCPN group, the Habib 4x RFA device was used to coagulate a margin of normal parenchyma around the renal mass to allow excision of the mass within a bloodless plane. Unlike in the LPN group, renal hilar vascular occlusion was not performed in the RF-RCPN group. RESULTS: Tumors treated in the RF-RCPN group tended to be larger (2.8 vs. 2.0 cm) and more often endophytic (52.6% vs. 16.1%). Collecting system reconstruction occurred more often in the RF-RCPN group (78.6% vs. 30.6%). Operative duration was longer in the RF-RCPN group (373 vs. 250 minutes), but this included time for cystoscopy, ureteral stenting, and repositioning of the patient. Blood loss, transfusion rates, renal function, and complication rates did not differ between the two groups. No patients required renal hilar vessel clamping or nephrectomy to control bleeding in the RF-RCPN group. CONCLUSIONS: The use of RFA-assistance during robotic partial nephrectomy allows excision of renal tumors without hilar vascular clamping, thus eliminating renal warm ischemia. Larger and more centrally located tumors were excised with RF-RCPN. No differences in blood loss, complication rate, postoperative bleeding, renal function, or recurrence rate were noted compared with LPN.

Outcomes of locally advanced (T3 or greater) prostate cancer in men undergoing robot-assisted laparoscopic prostatectomy.

OBJECTIVES: Despite nearly equivalent outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa), the role of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail. We report our experience with RALP for pathologically advanced disease. PATIENTS AND METHODS: From October 2005 to November 2008, 220 RALPs were performed by a single surgeon (R.B.N.). Outcomes were assessed prospectively in an institutional review board-approved database. RESULTS: Of 220 RALPs, 35 (15.9%) were performed for pT3 PCa; none of them were identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p = 0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p = 0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p = 0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on postsurgery questionnaires. CONCLUSIONS: RALP is a feasible approach to patients with pathologically advanced PCa as 71% were without evidence of disease at 13 months postoperatively. PSM rate (20%) is comparable to previously reported open PSM rates (24-66%).

Awake endotracheal intubation and prone patient self-positioning: anesthetic and positioning considerations during percutaneous nephrolithotomy in obese patients.

BACKGROUND AND PURPOSE: Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL. METHODS: Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia. RESULTS: We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3 kg/m(2)) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position. CONCLUSIONS: The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications.

Application of continuous tension to aid in performing the vesicourethral anastomosis for robot-assisted prostatectomy.

OBJECTIVES: Approximation of the bladder to urethra during robot-assisted laparoscopic prostatectomy (RALP) is a critical step toward achieving long-term continence. To determine the impact on surgical outcomes after RALP, we compare two techniques for constructing the vesicourethral anastomosis. METHODS: One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. The vesicourethral anastomosis was performed in a standard Van Velthoven fashion for the first 61 patients. The anastomosis in the remaining 93 patients was performed in a running fashion with the sutures under continuous tension applied by the surgical assistant and the third robotic arm. Operative times and surgical outcomes were recorded prospectively. RESULTS: When comparing standard Van Velthoven to continuous tension anastomosis, we demonstrate equivalent oncologic outcomes, continence and time required for the anastomosis. Yet, the frequency of complications related to the anastomotic technique, such as urine leaks, bladder neck contractures and migrated hemo-lock clips, were significantly lower with the continuous tension technique compared to the standard Van Velthoven running anastomosis. CONCLUSIONS: Performing the vesicourethral anastomosis under continuous tension demonstrated improved outcomes compared to the Van Velthoven anastomosis by allowing persistent close apposition of the bladder to urethra. Additionally, the learning curve associated with implementation of a new anastomotic technique was negligible.

A multi-institutional study on the safety and efficacy of specimen morcellation after laparoscopic radical nephrectomy for clinical stage T1 or T2 renal cell carcinoma.

INTRODUCTION AND OBJECTIVE: Specimen morcellation during laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) is controversial. We seek to evaluate the safety and efficacy of specimen morcellation and LRN for treatment of presumed malignant renal lesions. METHODS: We retrospectively reviewed all patients who underwent LRN at three academic institutions from 1996 to 2007. One hundred eighty-eight patients underwent specimen morcellation after LRN for enhancing solid or cystic renal masses. RESULTS: LRN was successfully performed on all the patients. Patient age ranged from 36 to 94. One hundred sixty-seven patients were in clinical stage T1, 19 patients T2, and unknown in two. The specimen was manually morcellated within a Cook Lap Sac or Endocatch II bag under laparoscopic or direct observation. On histological review of morcellated specimens, 165 patients were confirmed to have RCC, 17 had an oncocytoma, and 2 had benign cysts. At least 13 patients with RCC were pathologically upgraded to stage T3. Mean operative time was 225 minutes (range 94-650). Mean hospital stay was 2.5 days (range 1-8). In patients with RCC, 11 developed recurrent disease with mean follow-up of 21 months (range 0.3-111). In one patient, a port site recurrence occurred in concert with renal fossa and lymph node metastases. CONCLUSIONS: Intracorporeal mechanical morcellation after LRN appears to be safe and effective in clinical stage T1 and T2 RCC. This supports the use of morcellation as an alternative for intact specimen removal in properly selected patients.

Pathological guidelines for orthotopic urinary diversion in women with bladder cancer: a review of the literature.

PURPOSE: Before the early 1990s total urethrectomy at radical cystectomy for bladder cancer in women was considered the standard of care. As our understanding of the natural history of urethral urothelial carcinoma in women has improved, neobladders have been increasingly created in carefully selected women with bladder cancer. We reviewed the literature regarding the incidence of urethral involvement, the risk factors for urethral involvement and the incidence of urethral recurrence in women undergoing orthotopic urinary diversion for bladder cancer. MATERIALS AND METHODS: A comprehensive literature review was performed regarding the natural history of urethral tumor involvement by urothelial carcinoma, risk factors and the incidence of urethral recurrence following radical cystectomy and orthotopic diversion in women with bladder cancer. RESULTS: Urethral tumor involvement occurs in approximately 12% of female patients with bladder cancer undergoing radical cystectomy for high grade, invasive urothelial carcinoma. Preoperative involvement of the bladder neck or anterior vaginal wall with urothelial carcinoma is an important risk factor for urethral tumor involvement. Intraoperative frozen section analysis of the proximal urethra is an appropriate and reliable method of identifying female candidates for orthotopic diversion. The rate of secondary tumor recurrence in the retained urethra of women following radical cystectomy and orthotopic urinary diversion is low but the condition requires long-term followup. CONCLUSIONS: Orthotopic urinary diversion can be performed safely in appropriately selected women with bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence. Preoperative bladder neck involvement is an important risk factor for urethral involvement but not an absolute contraindication to orthotopic diversion should intraoperative frozen section of the proximal urethra be without evidence of malignancy.

Pathologic guidelines for orthotopic urinary diversion in women with bladder cancer: a review of the literature.

Orthotopic lower urinary tract reconstruction to the native intact urethra following radical cystectomy for bladder cancer was slower to gain clinical acceptance for women than for men. Until the 1990s, little was known about the natural history of urethral involvement by urothelial carcinoma in women with primary bladder cancer. The increasing availability of pathologic data to define the incidence of and risks for urethral involvement in women sparked an increasing interest in orthotopic diversion in female patients. Pathologic guidelines have been suggested to identify women suitable for orthotopic diversion. Preoperative involvement of the bladder neck is a significant risk factor for secondary tumor of the urethra, but is not an absolute contraindication, as long as full-thickness, intraoperative frozen-section analysis demonstrates no tumor involvement of the proximal urethra. Although less common, anterior vaginal wall tumor involvement may be a significant risk factor for urethral tumor involvement. Other pathologic parameters, including tumor multifocality, carcinoma in situ of the bladder, and tumor grade and stage, do not seem to be absolute contraindications. Long-term follow-up is critical for all patients. Women undergoing orthotopic reconstruction, if appropriately selected, should be assured of an oncologically sound operation and good function with their neobladder.

Alpha blocker therapy for children with dysfunctional voiding and urinary retention.

PURPOSE: Alpha blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective alpha blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying. MATERIALS AND METHODS: A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective alpha-1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating alpha blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating alpha blocker therapy. RESULTS: After starting doxazosin average PVR decreased to 8 ml (p <0.0001), representing an 88% reduction in residual urine (or reduction to only 2.7% of age expected bladder capacity). Medication was discontinued in 2 patients due to minor side effects. CONCLUSIONS: Selective alpha blocker therapy appears to be effective for improving bladder emptying in children with an overactive bladder, wetting, recurrent infection and increased PVR urine. This therapy may be used as either a replacement or in addition to biofeedback in patients with urinary retention. Further investigation, including a prospective randomized trial of alpha blocker therapy in children with urinary tract dysfunction, is warranted based on the findings of our study.