Ocular radiation exposure in modern urological practice.

PURPOSE: The human eye is a highly radiosensitive portion of the body and repeat radiation exposure can lead to cataract. The minimum fractionated long-term dose to initiate cataract formation is about 2,500 mSv. We determined whether further radiation related precautions are necessary to protect the eyes of the surgeon. MATERIALS AND METHODS: Radiation doses received near the right eye of the operating surgeon were measured with a thermoluminescent dosimeter badge worn near the eye of 6 urologists for a single endourological procedure at an academic center. Procedures included stent insertion, ureteroscopic lithotripsy and percutaneous nephrolithotomy. The mean radiation dose was calculated. Extrapolated doses required to potentiate cataract formation were also calculated. RESULTS: We assessed 28 urological procedures for radiation exposure, of which 13 were ureteroscopy done for calculus disease (range 0.05 to 0.66 mSv) and 7 were ureteral stent insertion (range 0.13 to 0.32 mSv). The mean radiation dose received during these cases was 0.208 mSv. Based on the mean dose and an average of 20 such cases per month, it would take about 50 years to reach the minimum threshold for progressive cataract formation. Eight percutaneous renal operations were performed and the mean dose received was 0.125 mSv (range 0.04 to 0.22). Based on 10 cases per month, this would require more than 160 years of exposure to reach the minimal threshold. CONCLUSIONS: Long-term radiation can lead to cataract formation. However, the accumulated lifetime exposure of the typical urologist may not necessitate further safety precautions, such as lead-lined glasses.

Robot-assisted laparoscopic sacrouteropexy for pelvic organ prolapse in classical bladder exstrophy.

Classical bladder exstrophy is a rare congenital anomaly with male predominance. When occurring in women, the accompanying anatomical and functional abnormalities, including pelvic organ prolapse (POP), may cause significant problems in both pediatric and adult patients. The robotic surgical approach to POP has not been described for bladder exstrophy as it has been in otherwise normal women. We report our technique with the first robot-assisted laparoscopic sacrouteropexy for Baden-Walker grade-four POP in an 18-year-old classical bladder exstrophy patient. At 12 months of follow-up, there were no issues or symptoms/evidence of recurrence of POP. To our knowledge, this is the first reported robot-assisted laparoscopic sacrouteropexy for POP in a previously repaired bladder exstrophy case. This procedure may be a viable option in selected patients.

Robot-assisted laparoscopic skills development: formal versus informal training.

INTRODUCTION: The learning curve for robotic surgery is not completely defined, and ideal training components have not yet been identified. We attempted to determine whether skill development would be accelerated with formal, organized instruction in robotic surgical techniques versus informal practice alone. MATERIALS AND METHODS: Forty-three medical students naive to robotic surgery were randomized into two groups and tested on three tasks using the robotic platform. Between the testing sessions, the students were given equally timed practice sessions. The formal training group participated in an organized, formal training session with instruction from an attending robotic surgeon, whereas the informal training group participated in an equally timed unstructured practice session with the robot. The results were compared based on technical score and time to completion of each task. RESULTS: There was no difference between groups in prepractice testing for any task. In postpractice testing, there was no difference between groups for the ring transfer tasks. However, for the suture placement and knot-tying task, the technical score of the formal training group was significantly better than that of the informal training group (p < 0.001), yet time to completion was not different. CONCLUSION: Although formal training may not be necessary for basic skills, formal instruction for more advanced skills, such as suture placement and knot tying, is important in developing skills needed for effective robotic surgery. These findings may be important in formulating potential skills labs or training courses for robotic surgery.

Supracervical robotic-assisted laparoscopic sacrocolpopexy for pelvic organ prolapse.

BACKGROUND: Supracervical robotic-assisted laparoscopic sacrocolpopexy (SRALS) is a new surgical treatment for pelvic organ prolapse that secures the cervical remnant to the sacral promontory. We present our initial experience with SRALS in the same setting as supracervical robotic-assisted hysterectomy (SRAH). METHODS: Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of greater than or equal to 3 who had not undergone hysterectomy were offered SRALS in combination with SRAH. A chart review was performed to analyze operative and perioperative data. Outcome data also included patients who underwent robotic-assisted laparoscopic sacrocolpopexy (RALS) without any other procedure. RESULTS: Thirty-three patients underwent RALS, including 12 patients who underwent SRALS. All SRALS were performed following SRAH in the same setting. The mean follow-up for the RALS and SRALS patients was 38.4 months and 20.7 months, respectively. One patient in the RALS group had an apical recurrence. There were no recurrences in the SRALS group. CONCLUSIONS: SRALS is effective for repair of apical vaginal defects in patients with significant pelvic organ prolapse who have not undergone previous hysterectomy. Complications are few and recurrences rare in short- and medium-term follow-up. Greater follow-up and numbers are needed to further establish the role of this procedure.

Large bladder diverticulum presenting as an inguinal hernia.

We present the case of a 76-year-old man with a large bladder diverticulum presenting as an inguinal hernia with small bowel incarceration. Bladder herniation is extremely rare and when clinically suspected, computed tomography can be an important adjunct to diagnosis.

Renal insufficiency is not a contraindication for cryoablation of small renal masses.

OBJECTIVE: Small, incidental renal masses are increasingly discovered in elderly patients with comorbid disease, such as chronic renal insufficiency (CRI). Observation of these masses or nephron-sparing surgery is the standard of care for these patients if possible. Laparoscopic renal cryotherapy (LRC) has been shown to be equivalent to laparoscopic partial nephrectomy in short-term follow-up for management of these masses. We evaluated the effect of LRC in this subset of patients and compared it with the effect in a group of patients who were undergoing the same procedure and who had normal renal function. PATIENTS AND METHODS: Patients with CRI undergoing LRC for small enhancing renal masses were retrospectively evaluated for renal function changes after surgery. From February 2001 to July 2007, 123 patients underwent LRC; 77 of these had preoperative and postoperative creatinine levels (Cr) for evaluation, and 14 of these had renal insufficiency. Renal insufficiency was defined as a Cr level >1.3 mg/dL. Creatinine clearance (CrCl) was calculated by the Modification of Diet in Renal Disease equation. Complications were reviewed. RESULTS: In patients with renal insufficiency, the mean preoperative Cr level was 2.39 mg/dL and postoperative Cr level was 2.24 mg/dL (P = 0.0497); the mean preoperative CrCl was 32.3 mL/min/1.73 m(2) and postoperative CrCl was 35.2 mL/min/1.73 m(2) (P = 0.034). In patients with normal function, the mean preoperative Cr level was 0.95 mg/dL and the postoperative Cr level was 0.93 mg/dL (P = 0.33); mean preoperative CrCl was 78.6 mL/min/1.73 m(2) and postoperative CrCl was 81.6 mL/min/1.73 m(2) (P = 0.19). CONCLUSIONS: LRC appears to have minimal impact on renal function as measured by serum Cr levels. LRC is nephron sparing and can be performed regardless of preoperative renal function.

Robot-assisted laparoscopic sacrocolpopexy as management for pelvic organ prolapse.

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical management option for pelvic organ prolapse that secures the apex of the vagina to the sacral promontory. Limited literature exists on outcomes of this procedure. We present our initial experience with RALS. PATIENTS AND METHODS: Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of 3 or greater were offered RALS without any other procedure. Chart review was performed to analyze operative and perioperative data, including urodynamics (UDS) and Baden-Walker classification before and after surgery. Data were analyzed with comparison of presurgical and postsurgical data. RESULTS: From July 2005 through July 2007, 21 patients underwent RALS. Blood loss was negligible. Average operative time, including robot docking, was 3 hours, 14 minutes. Nineteen patients were discharged on postoperative day 1. UDS were not changed significantly. One patient had an apical recurrence. There were no operative complications or conversions; however, one patient had a small bowel obstruction 5 days after surgery necessitating laparotomy. Of the 21 patients, 12 have undergone anterior and posterior repair, 5 await repair, and 4 patients have opted for conservative management. CONCLUSIONS: RALS is effective to repair apical vaginal defects in patients with significant pelvic organ prolapse. Operative time is manageable and complications are few. Cystocele, rectocele, and UDS remain essentially unchanged by RALS. Most, if not all, patients with cystocele and rectocele will need further vaginal reconstruction after RALS, if desired. Greater follow-up and numbers are needed to further establish the role of this procedure.

Intraoperative cystoscopic stent placement in robot-assisted pyeloplasty: a novel and efficient technique.

INTRODUCTION: Robot-assisted pyeloplasty (RAP) is a minimally invasive approach for repair of ureteropelvic junction obstruction. Ureteral stent placement is a necessary step that may necessitate additional procedures and/or radiation exposure for placement and confirmation of stent location. These may prolong operative times and increase morbidity. PATIENTS AND METHODS: Unique patient positioning and draping allow access to the urethra for intraoperative cystoscopy. As the surgeon performs the posterior portion of the Anastomosis, the assistant performs simultaneous flexible cystoscopy and retrograde stent placement. Stent location is confirmed by direct vision. RESULTS: This technique has been performed in 30 consecutive patients without difficulty or complication. CONCLUSION: This novel technique is a simple and efficient method of stent placement during RAP. It is performed simultaneously without the need for additional procedures, repositioning, or radiation exposure. Application of this technique may result in decreased operative time.

Increasing the number of biopsy cores before renal cryoablation increases the diagnostic yield.

BACKGROUND AND PURPOSE: Renal cryoablation has been established as a primary management option for many small renal masses. Biopsy is performed intraoperatively and typically consists of one core being taken. This method was used to reduce the potential for seeding tumor and to minimize bleeding, although there have been no reports of tumor formation caused by biopsy seeding and blood loss is minimal. It is also associated with a relatively high yield of nondiagnostic cores. As such, in March 2005, we began taking three biopsy cores rather than one in an attempt to decrease our nondiagnostic rate. MATERIALS AND METHODS: Biopsy results were retrospectively reviewed for patients who underwent renal cryoablation by two surgeons between February 2001 and July 2007. Findings were stratified according to the number of cores taken, which was either one or three. Tests for significance were performed using the chi-square test to determine if there was a difference in the nondiagnostic rates and the cancer yield rates. RESULTS: Results of 119 biopsies were reviewed. Of those, a single core was taken from 81 (68%) lesions. Of these, 49 (60%) were malignant and 14 (17%) were nondiagnostic. The remaining 38 (32%) had three cores taken. Twenty-seven (71%) of these were malignant and two (5%) was nondiagnostic. The P values for cancer yield rates and nondiagnostic rates were 0.248 and 0.030, respectively. CONCLUSIONS: Using a three-core biopsy strategy resulted in an 11% increase in cancer yield and a 12% reduction in nondiagnostic rate. Decreasing the nondiagnostic rate may help in counseling patients at follow-up. Continued investigation is warranted and under way.

Laparoscopic pyelolithotomy: indications and technique.

BACKGROUND AND PURPOSE: Laparoscopic pyelolithotomy, although uncommonly performed, may be considered in patients who have renal anomalies, are poorly compliant, and have a large single renal-pelvic calculus. We present our experience with this procedure in five patients. PATIENTS AND METHODS: Three patients underwent laparoscopic pyelolithotomy because of a horseshoe kidney, one for a pelvic kidney, and one for a large renal-pelvic calculus. All stones were solitary with a mean size of 2280 mm2 (range 540-8200 mm2). All were approached transperitoneally with passage of a flexible cystoscope through a laparoscopic port to aid in stone extraction. RESULTS: All cases were completed laparoscopically. The length of surgery was 74, 92, 134, 158, and 159 minutes. There were no minor or major complications, and the estimated blood loss was <50 mL in all cases. All patients were discharged on postoperative day 1 with the drains removed. Four patients were stented for 4 to 6 weeks. The remaining patient was not stented because of poor compliance. The stents were removed with office cystoscopy. All patients were stone free on follow-up imaging. CONCLUSIONS: Laparoscopic pyelolithotomy can be done safely, effectively, and efficiently with proper patient selection and adherence to standard laparoscopic surgical principles.

Prognostic significance of CD44, platelet-derived growth factor receptor alpha, and cyclooxygenase 2 expression in renal cell carcinoma.

CONTEXT: Pathologic stage is the main prognostic factor for predicting outcome in renal cell carcinoma (RCC). Because of its unreliability in predicting tumor progression, other factors are needed to provide additional prognostic information. OBJECTIVE: The expression of CD44, cyclooxygenase 2, and platelet-derived growth factor receptor alpha (PDGFR-alpha) was evaluated as a potential prognostic factor for survival in patients with RCC. DESIGN: Sixty-two patients (42 men and 20 women; median age, 61 years), undergoing partial (10 cases) or radical (55 cases) nephrectomy for RCC were retrospectively analyzed by immunohistochemical analysis for CD44, cyclooxygenase 2, and PDGFR-alpha expression. Impact of various factors on disease-specific and overall survival was calculated using Cox proportional hazards models. RESULTS: There was a gradual increase in CD44 and cyclooxygenase 2 expression with increasing RCC nuclear grade. In contrast, PDGFR-alpha expression showed no consistent relationship with nuclear grade. On univariate analysis, metastasis at time of surgery (P < .001), tumor size (P = .004), pathologic stage group (P = .001), and nuclear grade (P = .004) were correlated with disease-specific survival. On multivariate analysis, only the presence of metastasis at diagnosis (P < .001) was significant. For overall survival, metastasis (P < .001), tumor size (P = .02), pathologic stage group (P = .01), nuclear grade (P = .003), and PDGFR-alpha (P = .03) were significant on univariate analysis. Only metastasis (P = .001) and PDGFR-alpha (P = .03) were significant on multivariate analysis. CONCLUSIONS: When combined with other variables, PDGFR-alpha expression in RCC may provide additional predictive value related to the patient's overall survival. However, CD44 and cyclooxygenase 2 do not seem to be independent prognostic indicators in predicting outcomes for patients with RCC.