A Retroperitoneal Serous Cystadenoma of Müllerian Origin Masquerading as a Massive Renal Cyst.

A 78-year-old woman presented to the urology clinic with a large, symptomatic left-sided abdominal cyst that was believed to be renal in etiology for many years and that had been percutaneously drained 3 times previously with persistent regrowth. The patient underwent laparoscopic resection of this mass, which proved to be a completely distinct retroperitoneal cystic structure and was not renal in nature. Pathologic analysis ultimately revealed a rare occurrence: a benign retroperitoneal Müllerian serous cystadenoma. To our knowledge, this is the first report of such an entity "disguised" as a renal cyst.

Seminal vesicle abscess following prostate biopsy requiring transgluteal percutaneous drainage.

Transrectal ultrasound guided biopsy (TRUSB) of the prostate directly contaminates the prostate with rectal flora. Patients commonly receive fluoroquinolone (FQ) antibiotics to prevent infection. Infectious complications following TRUSB are increasing. The most common offending organism is Escherichia coli (E. coli), with isolates of this bacteria showing growing resistance to FQs. We present to our knowledge the first reported case of seminal vesicle abscess formation after TRUSB. The abscess was initially not seen on computed tomography and eventually treated with percutaneous drainage by a transgluteal approach. We review literature on infectious complications following TRUSB with implications for future antibiotic prophylaxis.

Unclamped hand-assisted laparoscopic partial nephrectomy for predominantly endophytic renal tumors.

PURPOSE: To describe our initial experience with unclamped laparoscopic hand-assisted partial nephrectomy for predominantly endophytic renal masses in the setting of relative contraindication to warm ischemia. MATERIALS AND METHODS: Unclamped laparoscopic hand-assisted partial nephrectomy was performed on eight consecutive patients from June 2009 to March 2010. All patients had predominantly endophytic renal masses with a preferential enhancing rim noted on the pre-operative computed tomography. The unclamped hand-assisted approach was utilized for no warm ischemia, minimal blood loss, and enhanced visualization of the tumor bed with improved operative exposure. RESULTS: Mean age of the participants was 55.8 years. All patients underwent unclamped hand-assisted partial nephrectomy (ie, zero ischemia). Mean estimated blood loss was 368.8 cc (range, 100 to 800 cc) and mean operation time was 236.9 minutes (range, 175 to 272 minutes). There were no intra-operative complications and no open conversions. There was one grade II (ileus with small pneumothorax) and one grade IV (pulmonary embolism) in the 90-day peri-operative period. There was one positive surgical margin, which was recognized intra-operatively. CONCLUSION: While our results are preliminary, we feel this technique provides superior visualization and adequate hemostasis while preserving oncologic efficacy and renal function in this patient population.

Rectal injury during robot-assisted radical prostatectomy: incidence and management.

PURPOSE: Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management. MATERIALS AND METHODS: We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management. RESULTS: A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified. CONCLUSIONS: Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.

Management of post-prostatectomy erectile dysfunction.

The management of post-prostatectomy erectile function has been debated since the nerve sparing radical prostatectomy was first introduced. A number of penile rehabilitation protocols have been proposed with varying degrees of success and patient satisfaction. My management of post-prostatectomy erectile dysfunction has evolved based on an honest and critical appraisal of the literature and my own experience and research. A review of major studies published on the topic of post-prostatectomy penile rehabilitation is included here, in addition to a critical evaluation of my own clinical practice. After evaluating the efficacy of these various approaches, it is clear to me that a nerve sparing procedure is only one of many factors involved in recovering erectile function. Moreover, in addition to assessing a patient's goals and their motivation for erectile function after prostatectomy, setting appropriate patient expectations is paramount to avoiding patient frustration. A frank evaluation and discussion with a patient and their partner is paramount to managing these expectations. A "one size fits all" approach is not appropriate. Herein, I discuss the evolution of my approach to managing post-prostatectomy erectile dysfunction.

Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial.

PURPOSE: Posterior rhabdosphincter reconstruction following radical prostatectomy was designed to improve early urinary continence. We executed a randomized clinical trial to test this conjecture in men undergoing robotic radical prostatectomy. MATERIALS AND METHODS: We conducted a phase II randomized clinical trial intended to detect a 25% difference in 3-month continence outcomes defined by a patient response of 0 or 1 to question 5 of the Expanded Prostate Cancer Index Composite questionnaire urinary domain, comparing standard running vesicourethral anastomosis (controls) to posterior rhabdosphincter reconstruction followed by standard running vesicourethral anastomosis (posterior rhabdosphincter reconstruction treated). Patients had clinically localized prostate cancer and were blinded. Surgeons were notified of computer randomization after prostate excision. Further continence outcomes were assessed by analysis of Expanded Prostate Cancer Index Composite questionnaire questions 1 and 12, International Prostate Symptom Score and 24-hour pad weights. Statistical significance was defined as p <0.05 RESULTS: A total of 94 patients were randomized, 47 to each arm. Preoperative clinical and functional variables were equivalent between study arms. There were no complications associated with either anastomotic technique. Of the 87 evaluable patients 62 (71.3%) met our 3-month continence definition. The null hypothesis was not rejected as 33 (81%) controls and 29 (63%) posterior rhabdosphincter reconstruction treated patients were continent at 3 months (chi-square p = 0.07, Fisher exact p = 0.1). Likewise there was no significant difference between arms in 24-hour pad weights (p = 0.14), International Prostate Symptom Score (p = 0.4), absence of daily leaks (p = 0.4) or perception of urinary function (p = 0.4). CONCLUSIONS: In this randomized clinical trial posterior rhabdosphincter reconstruction offered no advantage for return of early continence after robotic assisted radical prostatectomy.

Changes in penile length after robot-assisted laparoscopic radical prostatectomy.

BACKGROUND AND PURPOSE: Radical prostatectomy is commonly performed for the treatment of patients with prostate cancer. Several studies have demonstrated a reduction in penile size after open radical retropubic prostatectomy. The objective of this study is to describe changes in penile length after after robot-assisted laparoscopic radical prostatectomy (RALRP). PATIENTS AND METHODS: We performed a randomized, open label, multicenter study in men with normal erectile function who underwent bilateral nerve-sparing radical prostatectomy. We evaluated changes in measured stretched penile length (SPL), a secondary end point of the study, in a subset of men from a single site who underwent RALRP by one surgeon. They were randomized to either intraurethral alprostadil 125 to 250 µg daily or oral sildenafil citrate 50 mg daily for 9 months. SPL was measured from pubic bone to coronal sulcus using a semirigid ruler before surgery and at 1, 3, 6, 9, 10, and 11 months. RESULTS: A total of 127 patients were enrolled and 94 completed the 11-month follow-up. The mean patient age was 56.5 years. Baseline mean SPL (cm) before surgery was 11.77 and decreased to 11.13 at 1 month (P<0.0001). A trend toward recovery of SPL was seen at 3 and 6 months. Mean SPL was not significantly different from baseline at 9, 10, and 11 months. CONCLUSIONS: This report describes changes in SPL over time after RALRP for prostate cancer. The expected decrease in length was observed shortly after surgery, but, by 9 months, penile length had returned to the preoperative measurement.

Oncologic outcome of robot-assisted laparoscopic prostatectomy in the high-risk setting.

BACKGROUND AND PURPOSE: Previous studies have demonstrated the feasibility of open radical prostatectomy in the high-risk setting. Management of high-risk disease with robot-assisted laparoscopic radical prostatectomy (RALP) is controversial. We examined biochemical recurrence in a selected cohort of high-risk patients who were undergoing RALP. PATIENTS AND METHODS: Men with high-risk prostate cancer who underwent bilateral nerve-sparing, nonsalvage RALP by a single surgeon without adjuvant or neoadjuvant therapy of any kind were identified. High risk was defined by preoperative prostate-specific antigen (PSA) level >10 ng/dL, Gleason score ≥8 on final pathologic evaluation, or stage ≥pT(3). Postoperative PSA value ≥0.2 ng/dL defined biochemical recurrence. RESULTS: A total of 73 men were identified. There was no significant difference in surgical margin positivity (38% overall) or prostate size between recurrence and nonrecurrence cohorts. Biochemical failure was significantly associated with higher pathologic Gleason score (P = 0.0085) but not pathologic stage (P = 0.22) or preoperative PSA level (P = 0.18). With follow-up to 85 months (mean 31.8 mos), biochemical recurrence-free survival was 77% with mean time to recurrence of 7.7 months. Recurrence occurred significantly earlier than later (P < 0.001). CONCLUSIONS: Reasonable short- to intermediate-term biochemical outcomes can be achieved in a recurrence-prone group of high-risk men who are undergoing RALP. RALP is feasible in a selected cohort of high-risk men who are undergoing aggressive local therapy.

Vascular pseudoaneurysms in urology: clinical characteristics and management.

BACKGROUND AND PURPOSE: Vascular pseudoaneurysm is a well-documented complication that results after injury to an arterial wall. We review the urologic literature for all reported postprocedural and post-traumatic cases of pseudoaneurysm. METHODS: A comprehensive review of the peer-reviewed literature was performed for reported cases of vascular pseudoaneurysm, with emphasis on clinical presentation and treatment options. RESULTS: Vascular pseudoaneurysm is a high-pressure collection of blood that communicates directly with an arterial vessel. The clinical presentation varies, depending on the location and size of the lesion, and can be quite dramatic and potentially life threatening. There may be an increasing incidence of pseudoaneurysms after minimally invasive and laparoscopic techniques. Selective and superselective embolization is the preferred treatment for patients with vascular pseudoaneurysms. CONCLUSIONS: Vascular pseudoaneurysm is an important but rare complication that is increasingly reported after minimally invasive urologic surgery. This diagnosis necessitates a high index of suspicion and radiologic acumen. Treatment is individually tailored to each patient, but selective embolization appears to be the standard of care.

Recovery of erectile function after nerve sparing radical prostatectomy and penile rehabilitation with nightly intraurethral alprostadil versus sildenafil citrate.

PURPOSE: To our knowledge we report the first large, randomized, prospective penile rehabilitation clinical trial to compare the effectiveness of nightly intraurethral alprostadil vs sildenafil citrate after nerve sparing prostatectomy. MATERIALS AND METHODS: We performed a prospective, randomized, open label, multicenter American study in men with normal erectile function who underwent bilateral nerve sparing radical prostatectomy. The International Index of Erectile Function erectile function domain was the primary end point. Subjects initiated nightly treatment within 1 month of surgery with intraurethral alprostadil or oral sildenafil citrate (50 mg) for 9 months. After 1-month washout and before sexual activity subjects self-administered sildenafil citrate (100 mg) for a total of 6 attempts in 1 month. Secondary end points were the global assessment question, sexual encounter profile, Erectile Dysfunction Inventory of Treatment Satisfaction and measured stretched penile length. RESULTS: Of 139 men who started intraurethral alprostadil and 73 who started sildenafil citrate, 97 and 59, respectively, completed the trial. There were no statistically significant differences in International Index of Erectile Function erectile function domain and intercourse success rates to intraurethral alprostadil. The global assessment question was significantly better only at 6 months for intraurethral alprostadil (p <0.028). At completion there were no differences between treatments for any of the end points. CONCLUSIONS: This is the first study to directly compare the ability of alprostadil and a phosphodiesterase-5 inhibitor to enhance penile recovery subsequent to bilateral nerve sparing radical prostatectomy. The use of nightly subtherapeutic intraurethral alprostadil is well tolerated after radical prostatectomy. The benefit to return of erectile function of nightly sildenafil citrate and subtherapeutic intraurethral alprostadil appears to be comparable within the first year of surgery.

"Learning curve" may not be enough: assessing the oncological experience curve for robotic radical prostatectomy.

The use of robot-assisted laparoscopic radical prostatectomy (RALP) is widespread in the community. A definitive RALP "learning curve" has not been defined and existing learning curves do not account for urologists without prior advanced laparoscopic skills. Therefore, an easily evaluable metric, the "oncological experience curve," would be clinically useful to all urologists performing RALP. Positive surgical margin (PSM) status for all subjects undergoing RALP during the first 4 years of a single surgeon's experience was assessed. Univariate and multivariate analyses and logistic regression identified predictors of PSM creation and their correlation with surgeon case volume. The oncological experience curve was defined as the case point at which only pT2 stage, not surgeon volume (and thus surgeon inexperience), predicted PSM in the logistic regression. A total of 469 consecutive subjects comprised our cohort. Overall pT2 and pT3 PSM rates were 20% and 40%, respectively. Preoperative prostate-specific antigen, pathologic stage, and year of surgery were associated with PSM occurrence. Pathologic stage exclusively correlated to PSM in pT2 specimens for the first time during the fourth year, after 290 subjects had been treated. pT2 PSM rate before and after Case 290 was 25% and 10%, respectively (p < 0.001). The oncological experience curve is a clinically meaningful measure to evaluate the RALP learning curve for non-fellowship-trained urologists. The oncological experience curve may be much longer than the previously reported learning curves. Surgeons should consider whether they can build enough experience to minimize suboptimal oncological outcomes before embarking on or continuing a RALP program.

Bladder neck contractures related to the use of Hem-o-lok clips in robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: Recently, several large series of robot-assisted laparoscopic radical prostatectomy (RALP) have described a low incidence of bladder neck contractures (BNC). We have had a similar experience at our institution. Our objective is to describe our experience with BNC after RALP and a novel relationship to the use of Hem-o-lok Clips (HOLC). METHODS: We reviewed a database of patients who underwent RALP at our institution from January 2004 to September 2007 and identified patients with BNC or complications related to the use of HOLC. We performed a retrospective chart review to attempt to determine the cause of each BNC. We also performed a PubMed search and review of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. RESULTS: Of 524 patients undergoing RALP, 4 had a BNC develop, 2 of the BNCs were associated with HOLC migration and erosion into the vesicourethral anastomosis, and 1 was found to have HOLC migration within the bladder. A fifth patient had an anastomotic leak develop secondary to a HOLC that migrated into the bladder neck. Two similar cases of HOLC-related migration have been reported to MAUDE. CONCLUSIONS: When early BNC or unexplained urinary retention occurs after RALP, one should have a high index of suspicion for migration of HOLC. Clip use should be minimized on tissue immediately adjacent to the anastomosis, and every effort should be made to retrieve loose clips after the procedure.

Urodynamic evaluation of the human bladder response to an increase in outlet resistance.

AIM: We prospectively evaluated the response of the human bladder to a chronic increase in urethral resistance according to the indices of pressure, volume flow rate, total (external) bladder work, and maximum and average detrusor power. METHODS: Six men with incontinence after radical prostatectomy were evaluated urodynamically before and 3-6 months after undergoing a bulbourethral sling procedure. RESULTS: None of the men suffered from significant obstructive or irritative voiding symptoms preoperatively. Urodynamic evaluation showed postoperative increases in both average detrusor pressure and pressure at maximum flow, but there were no significant changes in voided volume, void time, or postvoid residual urine volume. Maximum detrusor power, average detrusor power, and total (external) bladder work were all significantly increased. CONCLUSION: These data confirm that the human bladder possesses a functional reserve, which is elicited by an increase in urethral resistance.