A diagnosis of prostate cancer and pursuit of active surveillance is not followed by weight loss: potential for a teachable moment.

BACKGROUND: Obesity is a risk factor for incident prostate cancer (PC) as well as risk of disease progression and mortality. We hypothesized that men diagnosed with lower-risk PC and who elected active surveillance (AS) for their cancer management would likely initiate lifestyle changes that lead to weight loss. METHODS: Patients were enrolled in the Prostate Active Surveillance Study (PASS), a multicenter prospective biomarker discovery and validation study of men who have chosen AS for their PC. Data from 442 men diagnosed with PC within 1 year of study entry who completed a standard of care 12-month follow-up visit were analyzed. We examined the change in weight and body mass index (BMI) over the first year of study participation. RESULTS: After 1 year on AS, 7.5% (33/442) of patients had lost 5% or more of their on-study weight. The proportion of men who lost 5% or more weight was similar across categories of baseline BMI: normal/underweight (8%), overweight (6%) and obese (10%, χ2 test P=0.44). The results were similar for patients enrolled in the study 1 year or 6 months after diagnosis. By contrast, after 1 year, 7.7% (34/442) of patients had gained >5% of their weight. CONCLUSIONS: Only 7.5% of men with low-risk PC enrolled in AS lost a modest (⩾5%) amount of weight after diagnosis. Given that obesity is related to PC progression and mortality, targeted lifestyle interventions may be effective at this 'teachable moment', as men begin AS for low-risk PC.

Prospective double-blind study of effect of ketorolac administration after laparoscopic urologic surgery.

BACKGROUND AND PURPOSE: To decrease postoperative dependence on narcotics for analgesia, we have evaluated ketorolac as an adjunct to perioperative pain control in patients undergoing laparoscopic urologic surgery. PATIENTS AND METHODS: Sixty-five patients (34 male, 31 female) were randomized to receive either ketorolac tromethamine (15-30 mg IV q 6 h) or placebo prior to laparoscopic surgery. Patient-controlled analgesia in the form of morphine sulfate was provided. Operative factors such as the type of surgery, operative time, and estimated blood loss were recorded. Postoperative factors such as analog pain score (range 0-10), narcotic usage, and length of stay were evaluated. RESULTS: Fifty-five patients completed the study. The average pain score was 2.2 and 4.5 for the ketorolac and placebo groups, respectively (P < 0.005). The mean amounts of total morphine used were 39.2 mg (ketorolac) and 62.5 mg (placebo) (P = 0.077). The length of stay was not significantly different in the ketorolac (2.5 days) and placebo (2.6 days) groups (P = 0.74). Operative times (P = 0.21) and estimated blood loss (P = 0.60) were not significantly different in the two groups. Ketorolac did not adversely affect renal function; serum creatinine changes were not significantly different from those in the patients receiving placebo (P = 0.50). Laparoscopic pyeloplasty necessitated more narcotic analgesia than did other laparoscopic procedures (P = 0.05). CONCLUSION: Ketorolac decreases the subjective perception of pain after laparoscopic urologic surgery. It is suggested that ketorolac administration decreases the amount of narcotic usage as well. Time to resumption of oral intake and length of hospital stay were not influenced by use of ketorolac.

Laparoscopic management of urachal cysts in adulthood.

PURPOSE: Managing persistent and symptomatic urachal anomalies requires wide surgical excision. Such intervention is recommended to prevent symptom recurrence and complications, most notably malignant degeneration. However, traditional open excision is associated with significant morbidity and prolonged convalescence. We report our experience with the laparoscopic excision of urachal remnants as a less morbid, minimally invasive surgical alternative. MATERIALS AND METHODS: Between October 1993 and December 1999, 4 patients with a mean age of 43.3 years who had a symptomatic urachal cyst underwent laparoscopic radical excision of the urachal remnant. Using 2, 10 mm. and 1 or 2, 5 mm. ports the urachus and medial umbilical ligaments were divided at the umbilicus cephalad to the cyst. The specimen, which included the urachus, cyst and medial umbilical ligaments, was then separated from the bladder dome with or without the bladder cuff and removed intact. We reviewed the perioperative records to assess morbidity, recovery and outcome. RESULTS: All 4 procedures were completed successfully. No intraoperative or postoperative complications were reported at a mean followup of 15 months (range 2 to 24). Mean operative time was 180 minutes (range 150 to 210) and average hospital stay was 2.75 days (range 1 to 4). Pathological evaluation confirmed a benign urachal remnant in each case. All patients resumed normal activity within 2 weeks. CONCLUSIONS: To minimize the morbidity of radical excision the laparoscopic management of benign urachal remnants in adulthood is efficacious and our preferred method of management.

Effect of time delay on surgical performance during telesurgical manipulation.

BACKGROUND: Telementoring allows a less experienced surgeon to benefit from an expert surgical consultation, reducing cost, travel, and the learning curve associated with new procedures. However, there are several technical limitations that affect practical applications. One potentially serious problem is the time delay that occurs any time data are transferred across long distances. To date, the effect of time delay on surgical performance has not been studied. MATERIALS AND METHODS: A two-phase trial was designed to examine the effect of time delay on surgical performance. In the first phase, a series of tasks was performed, and the numbers of robotic movements required for completion was counted. Programmed incremental time delays were made in audiovisual acquisition and robotic controls. The number of errors made while performing each task at various time delay intervals was noted. In the second phase, a remote surgeon in Baltimore performed the tasks 9000 miles away in Singapore. The number of errors made was recorded. RESULTS: As the time delay increased, the number of operator errors increased. The accuracy needed to perform remote robotic procedures was diminished as the time delay increased. A learning curve did exist for each task, but as the time delay interval increased, it took longer to complete the task. CONCLUSIONS: Time delay does affect surgical performance. There is an acceptable delay of <700 msec in which surgeons can compensate for this phenomenon. Clinical studies will be needed to evaluate the true impact of time delay.

Laparoscopic nephrectomy for autotransplantation.

Proximal ureteral injuries often require extensive reconstruction to repair. Management options include nephrectomy, ileal ureter interposition, extensive spiral bladder flaps, or autotransplantation. We report a patient who sustained a proximal ureteral avulsion and underwent a less invasive repair by way of a laparoscopic nephrectomy and subsequent autotransplantation.

Laparoscopic live donor nephrectomy.

Live donor renal transplantation has many advantages including greater graft and patient survival, shorter waiting periods, improved human leukocyte antigen matching, and less cold ischemia. Until recently, disincentives from the operation, such as prolonged hospitalization, postoperative pain, and significant convalescence, have deterred live donor renal transplantation. This article describes the technique of laparoscopic live donor nephrectomy and briefly reports the results. The procedure has resulted in improved postoperative recovery and shorter convalescence, with no effect on recipient renal function.

Duplicate bladder exstrophy: a unique approach to initial repair.

OBJECTIVES: To describe a unique approach to the management of duplicate bladder exstrophy combining initial bladder closure and epispadias repair. Bladder exstrophy has been successfully managed by staged surgical repair with early bladder closure, subsequent epispadias repair, and, finally, bladder neck reconstruction. Duplicate bladder exstrophy is a rare variant of the exstrophy complex with fewer than 20 cases reported. METHODS: A male newborn presented with the appearance of both bladder exstrophy and a ruptured omphalocele. Repair of the omphalocele and bilateral orchiopexy was performed shortly after birth, but bladder closure was delayed until there was complete healing of the omphalocele defect, and the investigators believed the infant was ready for abdominal wall and bladder exstrophy closure. At age 8 months, bladder closure was performed with the intraoperative finding of a duplicate bladder lying posterior to the exstrophied bladder. The left ureter drained on the exstrophic bladder plate, and the right ureter drained into the posterior (internalized) duplicate bladder. After anterior innominate and vertical iliac osteotomies, the left ureter was reimplanted into the posterior bladder. A portion of the exstrophied bladder was then tubularized to construct a neourethra of the epispadic penis. RESULTS: The child has done well with an excellent cosmetic appearance of the abdominal wall and a straight phallus. The bladder subsequently required a Mitrofanoff-type continent stoma along with bladder augmentation, which was performed at the time of his Young-Dees-Leadbetter bladder neck reconstruction (age 3.5). The child is currently continent but requires intermittent clean catheterization through his appendicovesicostomy. CONCLUSIONS: The investigators report a unique and unexpected variant of bladder exstrophy and its successful management.

Ureteroscopic management of intrarenal calculi.

PURPOSE: To determine its potential role in stone therapy, we evaluated our experience with the ureteroscopic removal of intrarenal calculi in 100 patients. We review the indications, techniques, stone-free and overall success rates, and complications. MATERIALS AND METHODS: From July 1994 to December 1996 ureteroscopic stone removal was attempted in 100 patients a mean of 52 years old who had renal calculi. Indications for treatment included concurrent ureteral stones in 56 cases, and failed extracorporeal shock wave lithotripsy, medical or percutaneous management as well as obesity and anatomical anomalies. There were 2 or more calculi in the affected kidney in 68 patients and stones greater than 6 mm. in 67. Treatment of intrarenal calculi was performed with flexible ureteroscopes, a laser or electrohydraulic lithotriptor and endoscopic graspers. The number and size of calculi were noted in each patient. Stone-free and overall success rates defined as 1 residual fragment less than 3 mm. were noted at 1 and 3-month followup visits. RESULTS: The overall success rate was 89%. Ureteroscopic treatment of intrarenal calculi resulted in a 77% stone-free rate. Of the 23 patients with residual calculi 12 (52%) had a single residual fragment less than 3 mm. The targeted stone was removed or fragmented in 98 patients (98%) and no ureteral calculi remained postoperatively. As expected, the number and size of the original stones inversely correlated with the success rate. There were no intraoperative complications, and only 3 urinary tract infections and 3 fevers were noted postoperatively. CONCLUSIONS: The use of smaller diameter ureteroscopes, better working instruments and more effective lithotriptors allow calculi in all parts of the collecting system to be engaged and treated. Success rates throughout the whole collecting system are comparable to if not better than those of extracorporeal shock wave lithotripsy and percutaneous approaches.

The role of renal scintigraphy in the evaluation of spinal cord injury patients with presumed urosepsis.

PURPOSE: We attempted to differentiate pyelonephritis, defined as upper urinary tract parenchymal infection, from fever due to other sources in patients with spinal cord injury by radioisotope renal scintigraphy. MATERIALS AND METHODS: A total of 13 consecutive spinal cord injury patients 21 to 54 years old (level of injury C4 to cauda equina) was hospitalized with urosepsis. The diagnosis was based on medical history, physical examination and laboratory evaluation, including blood, urine, sputum and wound fluid culture and sensitivity, and a 99mtechnetium glucoheptonate renal scan for pyelonephritis. Renal scan results were compared to 1 or more of several studies performed in each case, including ultrasonography, excretory urography and axial computerized tomography. RESULTS: Glucoheptonate renal scintigraphy accurately diagnosed pyelonephritis in all 7 patients with a scintigraphic B lesion. In 2 patients with a C lesion on scintigraphy, representing a cortical scar, other sources of sepsis were identified. In the 4 patients with negative renal scans pyrexia was attributed to active decubitus wound infection and osteomyelitis. Positive and negative predictive values of renal scanning were each 100%. CONCLUSIONS: Nuclear medicine renal scanning is a valuable adjunct in the evaluation of sepsis and presumed urosepsis in the spinal cord injury population.

Placement of ureteral stents in pregnancy using ultrasound guidance.

Urolithiasis is one of the most common causes of pain in pregnancy. Renal calculi can create a diagnostic and therapeutic challenge; left untreated, they can adversely affect maternal and fetal outcome. Although most cases of obstructive uropathy can be managed conservatively, some require relief of obstruction, usually by placement of a ureteral stent. We describe the use of ultrasound to identify an obstructed collecting system and provide guidance for placement of a double-pigtail ureteral stent in two pregnant patients. The technique used to manipulate the guide wire and stent into the renal pelvis under real-time ultrasound monitoring is discussed.