Robot assisted laparoscopic partial nephrectomy: initial experience.

PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach. MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups. RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group. CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy.

Robot-assisted laparoscopic partial nephrectomy.

The indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Nephron-sparing surgery, also known as partial nephrectomy, presents a challenge to the minimally invasive surgeon. Herein, we describe our technique of robot-assisted laparoscopic partial nephrectomy. This approach may have potential advantages of including easier excision and suturing. Moderate training is required.

Gunshot wounds: bullet caliber is increasing, 1998-2003.

In 1999, Caruso reported data from the level 1 trauma center in Newark, New Jersey, documenting "...an ominous trend toward the use of larger caliber firearms in accidents, homicides and suicides." Those data were derived from measurements of bullets removed from our trauma patients and submitted to the Surgical Pathology laboratory from 1981 through 1997. We further document this trend with measurements of similar source bullets from 1998 through 2002. During the same time, we recorded mortality among gunshot wound victims treated at our trauma center. Bullets submitted to surgical pathology during the years 1998 through 2002 were measured with a millimeter rule to determine caliber or transverse diameter. A total of 367 bullets were studied in this 5-year period. Bullets deformed beyond measurability (approximately 22%) and shotgun pellets (< 5%) were excluded from our study. Bullet calibers were expressed in terms of mean plus or minus standard error (x +/- SE). Mortality figures were derived from analysis of medical records concerning the outcomes all victims of gunshot wounds (E 922, E 965) treated at our hospital during the years studied and expressed as percentages. Linear regression of mean bullet caliber over time was performed, and analysis of variance was used to assess statistical significance of apparent differences in mortality. Bullet caliber continued to increase from 8.47 +/- 0.22 to 9.16 +/- 0.15 mm during the 5-year observation period. Linear regression reveals R = 0.9649, P < 0.01. Mortality ranged from 4.7 per cent to 10.7 per cent but the differences were not significant (P > 0.20). These data support a continued trend toward the use of larger caliber firearms in accidents, homicides, and suicides. Mortality does not change during this time and presumably because of improvements in treatment, from resuscitation to definitive surgery and its convalescence.

Altered N-myc downstream-regulated gene 1 protein expression in African-American compared with caucasian prostate cancer patients.

PURPOSE: The protein encoded by N-myc downstream-regulated gene 1 (NDRG1) is a recently discovered protein whose transcription is induced by androgens and hypoxia. We hypothesized that NDRG1 expression patterns might reveal a biological basis for the disparity of clinical outcome of prostate cancer patients with different ethnic backgrounds. EXPERIMENTAL DESIGN: Patients who underwent radical prostatectomy between 1990 and 2000 at Veterans Administration Medical Center of New York were examined. We studied 223 cases, including 157 African Americans and 66 Caucasians (T2, n = 144; >/=T3, n = 79; Gleason <7, n = 122; >/=7, n = 101). Three patterns of NDRG1 expression were identified in prostate cancer: (a) intense, predominately membranous staining similar to benign prostatic epithelium; (b) intense, nucleocytoplasmic localization; and (c) low or undetectable expression. We then examined the correlations between patients' clinicopathological parameters and different NDRG1 expression patterns. RESULTS: In this study of patients with equal access to care, African-American ethnic origin was an independent predictor of prostate-specific antigen recurrence (P < 0.05). We also observed a significant correlation between different patterns of NDRG1 expression and ethnic origin. Pattern 2 was less frequent in African Americans (21% versus 38%), whereas the reverse was observed for pattern 3 (60% in African Americans versus 44% in Caucasians; P = 0.03). This association remained significant after controlling for both grade and stage simultaneously (P = 0.02). CONCLUSIONS: Our data suggest that different NDRG1 expression patterns reflect differences in the response of prostatic epithelium to hypoxia and androgens in African-American compared with Caucasian patients. Further studies are needed to determine the contribution of NDRG1 to the disparity in clinical outcome observed between the two groups.

Use of fibrin glue and gelfoam to repair collecting system injuries in a porcine model: implications for the technique of laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: One of the challenges of laparoscopic partial nephrectomies is the repair of a collecting system injury. We hypothesized that fibrin glue plus Gelfoam could be sufficient to repair such injuries. MATERIALS AND METHODS: Four pigs (eight kidneys) underwent collecting system injuries of various lengths (3, 5, and 10 mm) (N = 8 each) during partial nephrectomy. Gelfoam soaked in the fibrin glue was applied to seal the collecting system and parenchymal defects. After 1 hour of passive filling, the renal pelvis was distended at supraphysiologic pressure to the point of leakage. Each repair site was examined for urinary extravasation during the physiologic and active phases of filling. RESULTS: Hemostasis was achieved, and all collecting system injuries, regardless of size, were free of urinary leakage at physiologic pressures. Moreover, all defects maintained a seal at supraphysiologic pressures of at least 50 cm H(2)O. CONCLUSION: The combined use of fibrin glue and Gelfoam is an effective means to obtain hemostasis and seal collecting system injuries up to 10 mm at physiologic pressures and up to 50 cm H(2)O in the acute setting. Our hope is that this technique can facilitate both laparoscopic and open partial nephrectomies. New technologies will be employed in an attempt to obtain better seating of the sealant plug in the future. Survival studies are in progress.