In vitro Comparison of the Mechanical and Optical Characteristics of 5 Disposable Flexible Ureteroscopes.

INTRODUCTION: Disposable (single-use) flexible ureteroscopes are alternatives to reusable ureteroscopes. With their superior surgical efficacy and safety in the presence of upper urinary calculi, disposable ureteroscopes aim to overcome the main limitations of conventional reusable ureteroscopes. However, studies on the performance of the most recently developed models of single-use flexible ureteroscopes are scarce. This study aimed to compare the in vitro performance of several recently introduced, single-use, flexible ureteroscopes. METHODS: Five disposable flexible ureteroscopes were tested in vitro to evaluate their mechanical and optical characteristics. To this end, their degrees of deflection, irrigation flow rates, and image qualities were investigated. The models examined were Innovex US31-B12, OTU-100RR, Redpine RP-U-C12, Sciavita SUV-2A-B, and Seplou URS3016E. Their performance was also compared with that of a reusable flexible ureteroscope, Olympus URV-F. RESULTS: The OTU device had the highest degrees of deflection and the smallest loop diameter of the disposable ureteroscopes. The single-use ureteroscopes had identical image resolutions at a distance of 1 cm. The Innovex and Redpine devices had the best color representation. CONCLUSIONS: Of the tested disposable ureteroscopes, the OTU device had the best mechanical attributes, given its small loop diameter, high deflection angles, and low irrigation flow loss. As to their optical properties, the resolutions of all 5 single-use models were identical at an image distance of 1 cm.

Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center.

Objective: Multiparametric magnetic resonance imaging (MRI) has become the standard of care for the diagnosis of prostate cancer patients. This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin (PSM) rates. Methods: We retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy (RP) at Siriraj Hospital between January 2013 and September 2019. PSM rates were compared between those with and without preoperative MRI. PSM locations were analyzed. Results: In total, 322 (30.1%) patients underwent MRI before RP. PSM most frequently occurred at the apex (33.2%), followed by posterior (13.5%), bladder neck (12.7%), anterior (10.7%), posterolateral (9.9%), and lateral (2.3%) positions. In preoperative MRI, PSM was significantly lowered at the posterior surface (9.0% vs. 15.4%, p=0.01) and in the subgroup of urologists with less than 100 RP experiences (32% vs. 51%, odds ratio=0.51, p<0.05). Blood loss was also significantly decreased when a preoperative image was obtained (200 mL vs. 250 mL, p=0.02). Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex. Neither the surgical approach, the neurovascular bundle sparing technique, nor the perioperative blood loss was associated with PSM. Conclusion: MRI is associated with less overall PSM, PSM at apex, and blood loss during RP. Additionally, preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP.

Surgical outcomes of patients who underwent retrograde intrarenal surgery using a ureteral access sheath to manage kidney stones sized 1-2 cm compared between patients who did and did not undergo preoperative ureteral stenting.

Objective: To investigate the surgical outcomes of patients who underwent retrograde intrarenal surgery (RIRS) using a ureteral access sheath (UAS) to manage kidney stones sized 1-2 cm compared between patients who did and did not undergo preoperative ureteral prestenting. Materials and methods: This retrospective cohort study included 166 patients (aged ≥18 years) who underwent RIRS at Siriraj Hospital (Bangkok, Thailand) during February 2015-February 2020. All patients had renal calculi (stone size: 1-2 cm) located within the pelvicalyceal system. 80 and 86 patients were allocated to the prestent and non-prestent groups, respectively. Patient baseline characteristics, renal stone details, operative equipment, stone-free rate (SFR) at 2 weeks and 6 months, and perioperative complications were compared between groups. Results: All patient baseline characteristics were similar between groups. At 2 weeks after surgery, the overall SFR was 65.1%, and the SFRs in the prestent and non-prestent groups were 73.4% and 59.5%, respectively (p = 0.09). At 6 months after surgery, the overall SFR was 80.1%, and the SFRs in the prestent and non-prestent groups were 90.7% and 79.3%, respectively (p = 0.08). The incidence of perioperative complications was not significantly different between groups. Conclusions: There was no significant difference in the SFR between the presenting and non-prestenting groups at both the 2-week and 6-month postoperative time points. There was also no significant difference in intraoperative and postoperative complications between groups. The SFR was higher at 6 months than at 2 weeks in both groups with no additional procedure.

Optimization of clinical risk-factor interpretation and radiological findings with machine learning for PIRADS category 3 patients.

BACKGROUND: Due to the low cancer-detection rate in patients with PIRADS category 3 lesions, we created machine learning (ML) models to facilitate decision-making about whether to perform prostate biopsies or monitor clinical information without biopsy results. METHODS: In our retrospective, single-center study, 101 eligible patients with at least one PIRADS category 3 lesion but no higher PIRADS lesions underwent MRI/US fusion biopsies between September 2017 and June 2020. Thirty additional patients were included as the validation cohort from the next chronological period from June 2020 to October 2020. Our ML research was a supervised classification problem, with a binary output based on pathological reports of cancerous or benign tissue. The clinical inputs were age, prostate-specific antigen (PSA), prostate volume, prostate-specific antigen density (PSAD), and the number of previous biopsies. The radiology-report inputs were the number of lesions, maximum lesion diameter, lesion location, and lesion zone. We subsequently removed the inputs with low importance. Logistic Regression, Support Vector Machine, Naive Bayes, Decision Tree, Random Forest, and eXtreme Gradient Boosting Tree (XGBoost) were employed. From receiver operating characteristic (ROC) curves, we determined Area Under the ROC Curve (AUC), the cut-off point, and sensitivity score (recall score) to evaluate the ML-model performance. RESULTS: Twenty-four adenocarcinoma patients had a mean age of 70 ± 5.79 years, a mean PSA of 12.42 ± 6.67 ng/ml, a mean prostate volume of 46.49 ± 23.13 ml, and a mean PSAD of 0.31 ± 0.22 ng/ml2 . Seventy-seven patients with benign tissue reports had a mean age of 66.39 ± 6.66 years, a mean PSA of 11.31 ± 7.50 ng/ml, a mean prostate volume of 65.25 ± 35.88 ml, and a mean PSAD of 0.19 ± 0.13 ng/ml2 . On the validation cohort, XGBoost had the best AUC of 0.76, which considered 80% sensitivity and 72% specificity at a probability cutoff of 57%. The remaining possible ML models performed worse with lesser AUC. The worst was Naïve Bayes, with AUC of 0.50. CONCLUSIONS: ML models facilitate PIRADS 3 patient selection for MRI/US fusion biopsies. ML could optimize how we use previously known clinical risk factors to their full potential.

The effect of laser fiber on the damage of the working channel of a flexible ureteroscope.

INTRODUCTION: Flexible ureteroscopy involves expensive equipment that is expensive to repair. This study aimed to investigate the effects of cleavage by various tools on the laser fiber tip and to determine the extent of damage incurred to the laser passing through the working channel and firing at different degrees of deflection. MATERIALS AND METHODS: We investigated the effect of cleavage on Lumenis Slimline reusable fibers (272 and 365 µm) as performed by four cleavage tools: a scribe pen, a surgical blade, suture scissors, and ceramic scissors. Following cleavage, we recorded the pattern of light dispersion and power output. The laser fibers passed through the working channel at various. RESULTS: The ceramic scissors provided the best pattern of light dispersion and the highest power output. The suture scissors provided unacceptable levels of light dispersion. The 272 µm fiber was able to pass through the working channel at 30 and 45 degrees of deflection. The 365 µm laser fiber was only able to pass through the working channel at 30 degrees of deflection. There was no breakage of the laser fiber at any of the degrees of deflection evaluated. CONCLUSIONS: Analysis showed that the ceramic scissors were the best tool for cleaving Lumenis Slimline reusable fibers and that suture scissors were unacceptable. We also found that the deflection angle that causes damage to the working channel by laser insertion is dependent on both the size of the laser fiber and the degree of bending. Firing the laser during scope deflection could be performed safely at any degree of deflection, even with a high laser power of 40 W for a duration of 30 s.

The Application of Retrograde Intrarenal Surgery to Remove a Single Large Kidney Stone During Pregnancy.

PURPOSE: To report the application and outcome of retrograde intrarenal surgery (RIRS) to remove a large kidney stone during pregnancy. PATIENT AND METHODS: A 30-year-old woman presented with an infected kidney stone (3 cm in size) at 4 weeks of pregnancy. We decided to remove the stone due to the possibility of obstruction and infection and chose to carry out this procedure by RIRS. In order to avoid complications associated with anesthetic, the surgery was carried out after the infection had cleared and when the patient had entered the second trimester of pregnancy. First, we used an ureteral access sheath and semi-rigid ureteroscopy to evaluate the ureteral lumen. We confirmed that the ureteral access sheath had been positioned appropriately by direct visualization with a flexible ureterorenoscope. The procedure was then carried out with a radiation-free protocol and without fluoroscopy. Ho-YAG laser lithotripsy was used to fragment the stones, and these fragments were then removed in a stone basket. The patient required three sessions of RIRS to remove the stone in its entirety; during this time, the patient was 18-29 weeks into her pregnancy. During each session, we removed approximately 30% of the stone. The patient developed fever after the first operation but responded fully to antibiotics. There were no perioperative complications, and the patient only remained in hospital for 3 days. The male infant was delivered by caesarian section at 37 weeks of pregnancy without any health complications. RESULTS AND CONCLUSION: We successfully removed a large kidney stone from a pregnant patient using an ureteral access sheath and RIRS without fluoroscopy. There were no complications indicating that this procedure can be carried out safely during pregnancy.

Factors Impacting Stone-Free Rate After Retrograde Intrarenal Surgery for Calyceal Diverticular Calculi.

OBJECTIVE: To evaluate the outcomes of retrograde intrarenal surgery (RIRS) treatment of calyceal diverticular calculi and identify the associated factors affecting post-operative stone-free rate. MATERIALS AND METHODS: From August 2015 to May 2019, data of 32 patients with calyceal diverticular calculi who were treated by RIRS in a Siriraj Hospital were retrospectively studied. All operations were performed by the same surgeon using flexible ureterorenoscopy (f-URS) and holmium YAG laser lithotripsy. Calyceal diverticula were identified by our refluxing technique and from the collected demographic, diverticular and stone data. Operative outcomes were retrospectively evaluated. Data were analysed to identify the factors associated with stone-free outcomes. Stone-free was defined as no residual stones remaining after surgery. RESULTS: Mean age of the patients was 55.7 years. Stone locations were non-lower pole in 81.2% of cases and lower pole for the remaining 18.8% of cases. Median stone size was 1.2 cm with three as the median number of stones per patient. Calcium oxalate was the most common stone composition (56.3%). Positions of the diverticulum were anterior calyx (34.4%) and posterior calyx (50%), while the remainder were undetermined (incomplete data). Average length of the diverticular neck was 0.4 cm. Mean operative time was 46 minutes and mean hospital stay was 2.9 days. Complications included fever in three patients (9.3%) and sepsis in two patients (6.3%), with overall post-operative stone-free rate at 75%. Factors significantly affecting stone-free status were stone size (P=0.003) and length of diverticular neck (P=0.038). Multivariate analysis determined that only stone size had a statistically significant effect on post-operative stone-free status (P=0.015). Cut off point for stone size that increased the chances of a post-operative stone-free outcome was less than 1.5 cm, as determined by the ROC curve. CONCLUSION: RIRS was found to be an effective and safe treatment option for the removal of calyceal diverticular calculi. Stone size of less than 1.5 cm offered a better chance of post-operative stone-free condition.

The correlation between demographic factors and upper urinary tract stone composition in the Thai population.

OBJECTIVE: To identify the correlation between demographic factors and upper urinary tract stone composition in the Thai population. METHOD: A retrospective observational study of first-time upper urinary tract stone former patients aged over 18 years who underwent stone surgery was performed in a tertiary referral university hospital from January 2013 to May 2018. Collected data included demographic information and stone composition information, which were analysed by the Fourier Transform-Infrared Spectroscopy (FTIR) method. The correlation between the demographic factors and major upper urinary tract stone composition was analysed using Fisher's exact test. RESULTS: A total of 480 patients were included in this study. The stones were 319 (66.5%) renal calculi and 161 (33.5%) ureteric calculi. There were 248 (51.7%) single composition stones and 232 (48.3%) mixed composition stones. The major stone compositions were 288 (60.0%) calcium oxalate (CaOx), 125 (26.0%) calcium phosphate (CaP), 40 (8.3%) uric acid (UA), 19 (4.0%) magnesium ammonium phosphate (MAP), five (1.0%) cystine, and three (0.6%) ammonium hydrogen urate (AHU). Gender was correlated with the major stone composition. In females, a correlation was found between the major stone composition and age, diabetes mellitus (DM), and glomerular filtration rate (GFR). The study showed no significant correlation between the major stone composition and dyslipidemia (DLP), hypertension (HT), gout, and body mass index (BMI) in both genders. CONCLUSION: Gender, age, DM, and GFR were the factors affecting the stone composition.

The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) with different arterial clamping techniques has increasingly been performed to avoid ischemic injury to nephron. However, postoperative renal function remains controversial. We determine the impact of each renal arterial clamping on surgical and renal outcomes after RAPN. MATERIALS AND METHODS: Patients who underwent RAPN at Siriraj Hospital from 2010 to 2016 were retrospectively reviewed and stratified into 3 cohorts: main-clamp (MAC), selective-clamp, and off-clamp. RESULTS: Main, selective, and off-clamping were performed in 27, 38, and 12, respectively. Median tumor size and Radius, Exophytic or endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to polar lines (RENAL) score were 3 cm and 7, respectively. Longer operative time was observed in MAC (p = 0.002) although estimated blood loss, transfusion rate, and complication were comparable. Warm ischemia time was not different between cohorts. However, number of patients with prolonged ischemia time in MAC were greater (p ≤ 0.01). All margins were negative. Median postoperative and latest glomerular filtration rate reduction were 3.8 and 5.3 mL/min/1.73 m2, respectively without significant difference between cohorts. On multivariable analysis, hypertension independently associated with reduced renal function preserved (p = 0.03). Median follow-up was 18 months. CONCLUSIONS: Our study is the first to report surgical and renal functional outcomes after RAPN in Southeast-Asian population. Based on our experience, clamping techniques does not impact on renal functions and complication rate was low even in small-volume center.

Comparison of urinary continence outcome between robotic assisted laparoscopic prostatectomy versus laparoscopic radical prostatectomy.

OBJECTIVE: To compare urinary continent rate at six and 12-month postoperative period, and perioperative outcome between robotic-assisted laparoscopic radical prostatectomy (RALP) and laparoscopic radical prostatectomy (LRP) at Siriraj Hospital. MATERIAL AND METHOD: All medical records of patients performed RALP and LRP between 2005 and 2010 were reviewed. Data composed of demographic information, perioperative outcome, and oncologic outcome. Moreover, the urinary continence rate was also collected at six and 12-month postoperative period by questionnaires based research design. RESULTS: Between 2005 and 2010, we performed 548 cases of RALP and 613 cases of LRP. Only 486 cases of RALP (88.6%) and 561 cases of LRP (91.5%) had been followed-up more than 12 months. All demographic data including age, biopsy Gleason score, and preoperative PSA level in both groups were comparably. On the other hand, the perioperative outcome in RALP differed from LRP group significantly, including operative time (210 min vs. 255 min), blood loss (449 ml vs. 766 ml), blood transfusion rate (7.6% vs. 25.2%), and length of hospital stay (7 days vs. 8.6 days) (p < 0.001). The oncological outcome including pathologic tumor staging and Gleason score were comparably. Late complication such as anastamosis stricture was not different between the two groups (3.1% in RALP vs. 2.4% in LRP, p = 0.584). The continence rate of RALP and LRP groups at 6-month was 67.8% and 39% and at 12-month was 80% and 63.7%, respectively. The continence rate of RALP was better than LRP significantly. CONCLUSION: From our experience, perioperative outcome and continence rate at six and 12-month of RALP group was significantly better than LRP group. The demographic data, oncological outcome, and anastamosis stricture rate were comparably in both groups. The most relevant preoperative predictors of urinary continence were patient's age and prostatic weight.

Laparoscopic radical prostatectomy: oncological and functional outcomes of 559 cases in Siriraj Hospital, Thailand.

OBJECTIVE: To evaluate the results of oncological and functional outcomes of laparoscopic radical prostatectomy (LRP) during the first five years experience in Siriraj hospital. MATERIALS AND METHOD: Between September 2004 and September 2009, the functional and oncological outcomes of 559 patients that underwent LRP were retrospectively evaluated. RESULTS: The distribution of pathological T stage was T2 (52.1%), T3 (39.9%), and T4 (2.9%). Lymph node metastasis (N1) were found in 19 patients (3.4%). The positive margin rates in pT2a-b, pT2c, pT3a, pT3b and pT4 were 13.2%, 34.7%, 65.9%, 72.7% and 76.9%, respectively. The 3-year biological progression free survival (bPFS) rate for all patients was 87.2%. Three-year bPFS rates in pT2a-b, pT2c, pT3a, pT3b and pT4 were 96.3%, 93%, 75%, 55.6% and 62.5% respectively. The continent rate at 12 months was 84% and potency rate at 12 months in group that received bilateral nerve sparing was 29.1%. CONCLUSION: The oncological and functional results of our first LRPs in Thai men are acceptable and compared well with the early experience of previous studies. However, longer follow up is needed for further evaluation.

Laparoscopic radical prostatectomy: perioperative outcomes and morbidity of 559 consecutive cases in Siriraj Hospital, Thailand.

OBJECTIVE: To evaluate perioperative outcomes and morbidity of laparoscopic radical prostatectomy in Siriraj Hospital during a 5-year experience. MATERIAL AND METHOD: Five hundred fifty nine patients who underwent laparoscopic radical prostatectomy (LRP) by seven surgeons at Siriraj Hospital between September 2004 and September 2009 were included in the study. Data of perioperative results and postoperative parameters were retrospectively evaluated. RESULTS: Mean operative time was 257 minutes SD 75 (range 125 to 680 min). The mean operative time of the first 100 cases was significantly higher than of the last 100 cases (307 ml/min SD 95 versus 223 ml/min SD 56; p-value = 0.001). Mean estimated blood loss was 779 ml SD 607 (range 40 to 6,000 ml). Of 559 patients, 148 patients (26.5%) had blood transfusions. The blood transfusion rate in the first 100 cases was significantly higher than those of the last 100 cases (36.5% versus 15%; p-value = 0.016). The median duration of catheterization time was 8 days. The mean time of drain insertion was 4.2 days SD 1.8 (range 2 to 18 days) postoperatively. Hospital stay was 8.8 days SD 7.6 (range 3 to 149 days). Overall perioperative complications rate was 17.1%. Of these patients, 13.4% were minor complication (Clavien 1, 2) and 3.7% were major complication (Clavien 3, 4). There were no mortalities. Late complication rate was 2.1%, which most of them were stricture of anastomosis. CONCLUSION: Perioperative outcomes and morbidity of LRP in a 5-year period were acceptable. Laparoscopic radical prostatectomy is technically demanding with an initially longer operative time and higher blood transfusion rate. The learning curve of the surgical team is needed to achieve good results.

Early experience of robotic assisted laparoscopic radical prostatectomy.

INTRODUCTION: Quality of life after laparoscopic radical prostatectomy has been a discussed issue among patients. Robotic Assisted Laparoscopic Radical Prostatectomy (RALRP) has been shown to provide the best surgical outcomes in terms of potency and continence. The program of robotic prostatectomy was started at Siriraj Hospital. Early result of the author's experience was evaluated. OBJECTIVE: To evaluate the feasibility of Robotic Assisted Laparoscopic Radical Prostatectomy done at Siriraj Hospital. MATERIAL AND METHOD: From March 2007 to November 2007, 34 patients (Group 1) with localized prostate cancer underwent Robotic Assisted Laparoscopic Radical Prostatectomy (RALRP). Perioperative data was evaluated and compared to those of 34 patients (group 2) who underwent Laparoscopic Radical Prostatectomy (LRP) during the same period by the same surgeon. RESULTS: There were no demographic differences between the two groups. Catheterization time was significantly shortened in the RALRP group (p < 0.05). There was no major complication in the RALRP group, one LRP patient suffered bilateral ureteric injuries and required bilateral reimplantation. In pathological T2 patients of the last 17 consecutive cases, positive surgical margin rate was similar (14%) in both groups. CONCLUSION: The author early experience has shown that RALRP is feasible and safe. Oncological outcome can be improved with more experience and long term follow up is needed to evaluate functional outcome including potency rate and incontinence rate.

Outcomes of surgical treatment for upper urinary tract transitional cell carcinoma: comparison of retroperitoneoscopic and open nephroureterectomy.

OBJECTIVES: To determine the surgical and oncologic outcomes in patients who underwent retroperitoneoscopic nephroureterectomy (RNU) in comparison to standard open nephroureterectomy (ONU) for upper urinary tract transitional cell carcinoma (TCC). PATIENTS AND METHODS: From April 2001 to January 2007, 60 total nephroureterectomy were performed for upper tract TCC at Siriraj Hospital. Of the 60 patients, thirty-one were treated with RNU and open bladder cuff excision, and twenty-nine with ONU. Our data were reviewed and analyzed retrospectively. The recorded data included sex, age, history of bladder cancer, type of surgery, tumor characteristics, postoperative course, disease recurrence and progression. RESULTS: The mean operative time was longer in the RNU group than in the ONU group (258.8 versus 190.6 min; p = 0. < 001). On the other hand, the mean blood loss and the dose of parenteral analgesia (morphine sulphate) were lower in the RNU group (289.3 versus 313.7 ml and 2.05 versus 6.72 mg; p = 0.868 and p = 0.018, respectively). There were two complications in each group. No significant difference in p stage and grade in both-groups (p = 0.951, p = 0.077). One patient with RNU had lymph node involvement, three in ONU. Mean follow up was 26.4 months (range 3-72) for RNU and 27.9 months (range 3-63) for ONU. No port metastasis occurred during follow up in RNU group. Tumor recurrence developed in 11 patients (bladder recurrence in 9 patients, local recurrence in 2 patients) in the RNU group and 14 patients (bladder recurrence in 13 patients, local recurrence in 1 patient) in the ONU group. No significant difference was detected in the tumor recurrence rate between the two procedures (p = 0.2716). Distant metastases developed in 3 patients (9.7%) after RNU and 2 patients (6.9%) after ONU. The 2 year disease specific survival rate after RNU and ONU was 86.3% and 92.5%, respectively (p = 0.8227). CONCLUSION: Retroperitoneoscopic nephroureterectomy is less invasive than open surgery and is an oncological feasible operation. Thus, the results of our study supported the continued development of laparoscopic technique in the management of upper tract TCC.

Retroperitoneoscopic nephrectomy in dialysis dependent patients and comparison with open surgery.

OBJECTIVE: To evaluate the surgical outcomes and morbidity of retroperitoneoscopic nephrectomy compared with open nephrectomy for dialysis dependent patients. MATERIAL AND METHOD: Between November 2002 and August 2007, 14 hemo or peritoneal dialysis patients underwent nephrectomy or nephroureterectomy at Siriraj Hospital. Of the 14 patients, seven were treated with retroperitoneoscopic nephrectomy and seven with open nephrectomy. A retrospective review and data were carried out. The patient factors, type of surgery, perioperative outcomes and complications were analyzed. RESULTS: There was no conversion rate in the retroperitoneoscopic group. The mean estimated blood loss, analgesic requirement and time before starting oral intake were lower in the retroperitoneoscopic group (141.4 +/- 95 versus 292.8 +/- 226 ml, 5.0 +/- 4.5 versus 7.6 +/- 1.9 mg and 14.5 +/- 16.1 versus 23.1 +/- 23.3 hours, respectively). On the other hand, the mean operative time in the retroperitoneoscopic group was longer than the open group but with no significant difference (177.14 +/- 51 versus 160.71 +/- 84 min, p = 0.521). Two patients in the open group required intraoperative blood transfusion. There were two complications. One patient developed a large retroperitoneal hematoma after retroperitoneoscopic nephrectomy. Another had a perivesical collection in the open nephrectomy group. No mortality related to the procedures occurred. CONCLUSION: Retroperitoneoscopic nephrectomy should be considered as the procedure of choice for dialysis dependent patients. This has all the benefits of minimally invasive surgery such as reduced blood loss, minimal post operative pain leading to faster convalescence.

Extraperitoneal laparoscopic radical prostatectomy: early experience in Thailand.

OBJECTIVE: The transperitoneal approach is the conventional technique for laparoscopic radical prostatectomy. There are, however, several disadvantages of the approach, such as damage to intraperitoneal organs and long-term ileus. To prevent these complications, we propose an extraperitoneal approach that has been successfully used for open radical prostatectomy in treating patients with localized prostate cancer. The aim of this study was to evaluate the feasibility of extraperitoneal laparoscopic radical prostatectomy (ELRP). The outcomes of ELRP and open radical prostatectomy were also assessed and compared. METHODS: There were two groups of patients with localized prostate cancer confirmed by transrectal ultrasound biopsy. Patients were included if they had no previous hormonal treatment and no previous transurethral prostatectomy. Group I comprised patients in whom open radical prostatectomy was performed between February 2001 and August 2005 ( n = 55). Group II comprised patients in whom ELRP was performed between December 2005 and October 2006 (n = 41). Early postoperative results, clinical outcomes and complications were analysed among the two groups using Chi-squared, t and Mann-Whitney tests. RESULTS: Group I and Group II did not show significant differences regarding age, clinical staging, hospitalization time, or pathological stage. Group II had a longer mean operative time than Group I (t test, p< 0.001). Median blood loss was significantly less in Group I (Mann-Whitney test, p < 0.001). Group II also demonstrated shorter catheter removal time (Mann-Whitney test, p = 0.003). In Group II, there were two rectal complications, including rectal injury and rectal necrosis, which were treated laparoscopically and conservatively without long-term problems. CONCLUSION: With experience, ELRP is feasible with equal oncological outcomes to open radical prostatectomy. Although a certain disadvantage was presented by ELRP, the less invasive surgery and reduction in operative blood loss were major advantages. It is suggested that a large and longitudinal trial be conducted to investigate the effectiveness of such an approach in managing functional outcomes.

Conventional laparoscopic partial nephrectomy for a small renal mass.

The authors report the first case series of conventional laparoscopic partial nephrectomy in Thailand Laparoscopic partial nephrectomy was successfully performed in two patients with small renal tumors. The first patient underwent transperitoneal laparoscopic partial nephrectomy for a 3.8 x 3.3 cm renal mass. Intraoperative blood loss was 100 ml with warm ischemic time of 38 minutes. Pathological report showed renal cell carcinoma. The patient proceeded with laparoscopic radical nephrectomy, as surgical margin was not free. The second patient underwent retroperitoneal laparoscopic partial nephrectomy for a 1.8 x 2.4 cm renal mass. Intra-operative blood loss was 200 ml with clamping time of 45 minutes. Pathological report showed angiomylipoma. Using two different approaches of laparoscopy, namely, transperitoneal and retroperitoneal approaches, patients gained benefit from small incision and fast recovery.

Nerve-sparing laparoscopic radical prostatectomy at Siriraj Hospital.

BACKGROUND: Quality of life after laparoscopic radical prostatectomy has been a discussed issue among patients. Nerve-sparing radical prostatectomy has been shown to be superior to non-nerve-sparing radical prostatectomy in terms of potency and continence. The authors have reported their experience of laparoscopic radical prostatectomy and now developed our technique of nerve-sparing laparoscopic radical prostatectomy. OBJECTIVE: To evaluate the feasibility of nerve-sparing laparoscopic radical prostatectomy done at our institute. MATERIAL AND METHOD: From December 2005 to August 2006, 28 patients with localized prostate cancer underwent a nerve-sparing laparoscopic radical prostatectomy. Perioperative data was compared to those 34 patients who underwent non-nerve-sparing laparoscopic radical prostatectomy during the same period. All patients had PSA of less than 10 and pre-operative Gleason Score of 7 or less. Quality of life including incontinence and impotency rates was analyzed during three months post-operation. RESULTS: Patients' dermographic data, except ages, was similar in the two groups. Operating time was not different (217 vs. 212 minutes in favor of nerve-sparing). Blood loss was significantly high in nerve-sparing laparoscopic radical prostatectomy (814 mls vs. 543 mls, p = 0.01). Tumor control was not different within both groups. Three months after surgery incontinent rates of both groups were not different. 43.75% of patients with nerve-sparing technique had experienced erection at three months after surgery. CONCLUSION: The authors' early experience has shown that nerve-sparing laparoscopic radical prostatectomy does not compromise cancer control, although blood loss is higher. This operation should be encouraged in cancer-localized patients as the patients may gain benefit of better quality of life.

Laparoscopic radical prostatectomy: transperitoneal laparoscopic radical prostatectomy versus extraperitoneal endoscopic radical prostatectomy.

OBJECTIVE: To compare the perioperative results between Transperitoneal Laparoscopic Radical Prostatectomy (T-LRP) and Extraperitoneal Endoscopic Radical Prostatectomy (E-LRP). MATERIAL AND METHOD: Retrospective reviews of 125 patients who underwent laparoscopic radical prostatectomy by single surgeon (C.N) for stage T2-T3 adenocarcinoma of the prostate between May 2001 and July 2006 at Siriraj Hospital. Fifty-six cases had T-LRP and 69 cases had E-LRP The preoperative data (age, presenting PSA, and Gleason score), perioperative data (prostatic weight, operative time, intraoperative blood loss, the day of full oral diet, length of drain, and catheter time), pathologic stage, and margin status were compared. RESULTS: Mean age and Gleason score were comparable in both groups. Mean presenting PSA was lower in T-LRP (9.93) as compared to E-LRP (21.84) (p = 0.046). The mean prostatic weight was comparable in both T-LRP and E-LRP. The mean operative time of T-LRP (350) was significant longer than E-LRP (220) (p < 0.001). Mean intraoperative blood loss was more in T-LRP (883) as compared to E-LRP (605) (p = 0.001). Average blood transfusion was higher in T-LRP (1.23 unit) as compared to E-LRP (0.32). Postoperative full oral diet, length of drain, and catheter time in E-LRP were shorter than T-LRP (full diet: median 2 days vs. 3 days, p = 0.001) (length of drain: 4.98 days vs. 6.69 days, p = 0.002) (Catheter time: 8.9 days vs. 11.9 days, p = 0.002). Margin status were comparable in both groups but mean postoperative Gleason score was higher in E-LRP as compared to T-LRP (7.2 vs. 6.85, p = 0.022). CONCLUSIONS: E-LRP resulted in significant less operative time, intraoperative blood loss, postoperative oral diet, length of drain and catheter time where as the pathological margin status was the same in both T-LRP and E-LRP.

Endoscopic extraperitoneal radical prostatectomy (EERPE): a new approach for treatment of localized prostate cancer.

UNLABELLED: Laparoscopic radical prostatectomy is usually performed by transperitoneal approach. Patients may encounter; intraperitoneal organs injury, and prolonged ileus during recovery period. The authors firstly performed endoscopic extraperitoneal radical prostatectomy (EERPE) in Thailand, which is mimicking open radical prostatectomy, the gold standard for treatment of localized prostate cancer. OBJECTIVE: Assess and evaluate the feasibility and early outcomes of the authors' experience in endoscopic extraperitoneal laparoscopic radical prostatectomy (EERPE). MATERIAL AND METHOD: From December 2005 to May 2006, 27 cases of EERPE were performed at the authors' institute for clinically localized prostate cancer by one surgeon (group I). Operative data was compared to those 55 patients who underwent open radical prostatectomy from February 2001 to August 2005 for early prostate cancer by the same surgeon (group II). Early postoperative results, clinical outcomes and complication were analyzed between the two groups using Chi-Square, student unpaired t-test and Mann-Whitney U tests. RESULTS: Patients' age and clinical staging were not different between the two groups. Mean operative time was longer in the EERPE group (268 minutes vs 157 minutes; p < 0.01). Median blood loss was 500 mls and 1000 mls in the EERPE and open groups, respectively (p < 0.001). The likelihood of transfusion rate in the open group was higher than the EERPE group, with odd ratio of 8.75 (95%CI = 2.09-39.86), p = 0.001. Hospitalization time and pathological stage were not different between the two groups. In the EERPE group, there were two rectal complications, including rectal injury and rectal necrosis, which were treated laparoscopically and conservatively without long-term problems. CONCLUSION: The authors' early experience has shown that EERPE is feasible. Although operative time was longer; the patients may gain benefit of minimally invasive surgery and decreased operative blood loss. In EERPE group, oncological outcomes are equal to open surgery, however more cases and long-term follow up are required to evaluate the efficacy of such an approach.