Interobserver reliability and reproducibility of s.T.o.N.e. Nephrolithometry for renal calculi.

PURPOSE: To assess the reliability of the S.T.O.N.E. (stone size [S], tract length [T], obstruction [O], number of involved calices [N], and essence or stone density [E]) nephrolithometry scoring system by testing its reproducibility between different observers. PATIENTS AND METHODS: Preoperative images of 58 patients who underwent percutaneous nephrolithotomy (PCNL) were reviewed. Medical students, urology residents, one fellow, and a urology attending independently reviewed all images and scored the renal stones. Interobserver reliabilities of the total score for all categories and each component were evaluated by the intraclass correlation (ICC) and a κ coefficient. RESULTS: The interobserver reliability for the total score demonstrated high correlations for all components and total score (ICC=S, T, O, N, E and total 0.80, 0.97, 0.89, 0.84, 0.91, and 0.87, respectively). κ rates for individual components between two medical students were 0.36, 1, 0.31, 0.45, 0.33, and 0.30 for the S, T, O, N, E components and total score, respectively. κ values between the two urology residents were 0.71, 1, 0.92, 0.79, 0.93, and 0.67 for S, T, O, N, E components and total score, respectively. κ values between the urology fellow and an attending physician were 0.95, 1, 0.88, 0.94, 0.89, and 0.87 for S, T, O, N, E components and total score, respectively. P value for all the scoring components was <0.05, indicating that the estimated κ was not a result of chance. CONCLUSIONS: The S.T.O.N.E. nephrolithometry has excellent interobserver reliability. Quantifying the S and N metrics was the most challenging and least reliable. Standardized protocols to measure these components should be considered to improve accuracy and reproducibility of the scoring system.

Screening rectal culture to identify fluoroquinolone-resistant organisms before transrectal prostate biopsy: do the culture results between office visit and biopsy correlate?

OBJECTIVE: To investigate the performance of screening rectal cultures obtained 2 weeks before transrectal prostate biopsy to detect fluoroquinolone-resistant organisms and again at transrectal prostate biopsy. MATERIALS AND METHODS: After institutional review board approval for observational study, we obtained a rectal culture on patients identified for a prostate biopsy but before antibiotic prophylaxis from September 12, 2011 to April 23, 2012. The specimen was cultured onto MacConkey agar with and without 1 µg/mL ciprofloxacin. We then obtained a second rectal culture immediately before prostate biopsy after 24 hours of ciprofloxacin prophylaxis. All cultures were blinded to the practitioner until the end of the study. RESULTS: Of 108 patients enrolled, 58 patients had both rectal cultures for comparison. The median time duration between cultures was 14 (6-119) days. There were 54 of 58 concordant pairs (93%), which included 47 negative cultures and 7 positive cultures; 2 patients (3%) who were culture negative from the first screening culture became positive at biopsy. Sensitivity, specificity, negative, positive predictive values, and area under the operator curve were 95.9%, 77.8%, 95.9%, 77.8%, and 0.868, respectively. When Pseudomonas spp. are removed from the analysis, the area under the curve is increased to 0.927. CONCLUSION: Screening rectal cultures 2 weeks before prostate biopsy has favorable test performance, suggesting screening cultures give an accurate estimate of fluoroquinolone-resistant colonization.

Genitourinary exam skills training curriculum for medical students: a follow-up study of comfort and skill utilization.

PURPOSE: We developed a genitourinary skills training (GUST) curriculum for incoming third year medical students (MS3) and performed a follow-up study of comfort with and utilization of these skills. MATERIALS AND METHODS: GUST consisted of a didactic lecture followed by skills sessions including standardized patient testicular examination (TE) and digital rectal examination (DRE), male and female Foley catheter (MFC and FFC) placement training, suture-knot tying, and a faculty-directed small group learning session. Precourse and postcourse, and 6 and 18 months after the course, MS3 rated comfort with each skill (Likert scale 0-5), and quantified skill usage. Results were compared with 4th year students (MS4) who had not undergone GUST. RESULTS: Participants were 281 MS3 GUST students and 44 MS4. Post-GUST, mean comfort on a Likert scale (0=uncomfortable) increased for all four skills (88.2%-96.9% vs 8.3%-18.5%, P<0.0001). This was maintained at the 6-month and 18-month follow up time points (P<0.0001). At 18 months, MS3 trended toward higher comfort with TE compared with MS4 (74 vs 54%, P=0.068), while with the other skills, both groups showed equal comfort. MS4 learned exam skills from faculty and MFC and FFC from nurses on the wards. Eleven percent of MS4 were never formally taught TE or DRE. MS3 and MS4 performed TE and/or DRE on <8% of newly admitted patients. CONCLUSIONS: MS3 described improved comfort with the GU skills at all time points during follow-up. This was particularly important because both MS3 and MS4 reported using their skills infrequently during their clinical training years.

Interobserver reliability of the RENAL nephrometry scoring system.

OBJECTIVE: To determine the reliability of the RENAL nephrometry scoring system by studying its reproducibility among different observers. METHODS: We reviewed computed tomography or magnetic resonance imaging scans from 51 patients who underwent partial nephrectomy at our cancer center. Digitized axial and coronal images were available for all patients. Three surgeons independently scored the renal tumors using the RENAL nephrometry system. The scoring system had 5 components: R (tumor diameter), E (exophytic/endophytic), N (nearness to collecting system), A (anterior/posterior), and L (location in relation to polar lines). Interobserver variability was calculated for each of the 5 components using a frequency procedure and Kappa statistics. RESULTS: The reliability assessed by frequency procedure showed concordance among 3 observers in 94%, 76%, 66%, 80%, and 54% for the R, E, N, A, and L components, respectively. The corresponding kappa values for each of these 5 components were 0.95, 0.86, 0.76, 0.84, and 0.73, respectively. CONCLUSION: The RENAL nephrometry scoring system has good interobserver reliability. Quantifying the tumor location (L) was more challenging and the least reliable of the 5 components. This variation might affect the total nephrometry score and should be considered when using the system to compare different series of patients undergoing partial nephrectomy.

Sprayed fibrin sealant as the sole hemostatic agent for porcine laparoscopic partial nephrectomy.

PURPOSE: Tisseel® is used to control minor bleeding during laparoscopic procedures. The DuploSpray MIS™ spray system allows thin, even application over a larger surface area. We use sprayed Tisseel as the sole agent to control hemorrhage and seal the renal collecting system after severe porcine laparoscopic partial nephrectomy. METHODS AND MATERIALS: We performed staged bilateral severe laparoscopic partial nephrectomy in 12 Yucatan pigs using a longitudinal cut from upper to lower pole through the entire collecting system. In each pig 1 kidney was harvested immediately while the other was harvested after 4 weeks. After hilar clamping laparoscopic partial nephrectomy was done with cold scissors in 6 pigs while LigaSure™ was used in the other 6. Sprayed Tisseel was applied, and bleeding and urinary leakage were evaluated. Additional Tisseel was applied for repeat bleeding. We performed retrograde pyelogram (chronic) and burst pressure testing of the arterial and collecting systems. RESULTS: All animals survived 4 weeks. One urinoma was seen on retrograde pyelogram in the cold cut group. Average hilar clamp time was similar in the acute and chronic study arms. Average estimated blood loss was significantly less in the LigaSure group (p = 0.0045). Average arterial burst pressure was significantly different in the chronic and acute groups (605.8 vs 350.4 mm Hg, p = 0.008) but average collecting system burst pressure was similar (186.3 and 149.5 mm Hg, respectively). CONCLUSIONS: Sprayed Tisseel without suturing effectively sealed the arterial and collecting system after severe laparoscopic partial nephrectomy in the porcine model.

Impact of a laparoscopic renal surgery mini-fellowship program on postgraduate urologist practice patterns at 3-year followup.

PURPOSE: To assist practicing urologists incorporate laparoscopic renal surgery into their practice we established a 5-day mini-fellowship program with a mentor, preceptor and a potential proctor at our institution. We report the impact of our mini-fellowship program at 3-year followup. MATERIALS AND METHODS: A total of 106 urologists underwent laparoscopic ablative (44) or laparoscopic reconstructive (62) renal surgery training. The 1:2 teacher-to-attendee experience included tutorial sessions, hands-on inanimate and animate skills training, and clinical case observations. Participants were asked to complete a detailed questionnaire on laparoscopic practice patterns 1, 2 and 3 years after the mini-fellowship. RESULTS: The questionnaire response rate at 1 to 3 years was 77%, 65% and 68%, respectively. Of responders 72%, 71% and 71% performed laparoscopic renal surgery at 1 to 3 years, respectively. Of the 106 participants 32 (39%) had previous laparoscopic experience, including 78% who responded to the questionnaire at 3 years. Of those surgeons there was an increase in the practice of laparoscopic radical nephrectomy (88% vs 72%), nephroureterectomy (56% vs 13%), pyeloplasty (40% vs 6%) and partial nephrectomy (32% vs 6%) at 3 years. Of the 106 participants 74 (70%) were laparoscopy naïve, including 48 (65%) who responded to the questionnaire at 3 years. The take rate in this group was 76%, 52%, 34% and 23% for laparoscopic radical nephrectomy, nephroureterectomy, pyeloplasty and partial nephrectomy, respectively. Of the participants 90% indicated that they would recommend this training to a colleague. CONCLUSIONS: An intensive 5-day laparoscopic ablative and reconstructive renal surgery course enabled postgraduate urologists to effectively introduce and expand the volume and breadth of their laparoscopic renal surgery practice.

Nephron-sparing surgery for pathological stage T3b renal cell carcinoma confined to the renal vein.

OBJECTIVE: To report the functional and oncological outcome of nephron-sparing surgery (NSS) for pathological stage pT3bNxMx (2002 Tumour-Node-Metastasis staging) renal cell carcinoma (RCC) with tumour thrombus confined to the renal vein. PATIENTS AND METHODS: Of the 305 patients who underwent NSS at our institute from October 2004 to July 2009, seven (2%) were found to have stage T3bNxMx RCC on final pathology. Their charts were reviewed to identify demographic, operative and pathology details of these patients, in addition to obtaining functional and oncological outcome data. RESULTS: All seven patients had centrally located endophytic tumours. There were absolute indications for NSS in six patients (solitary kidney in five, renal insufficiency in one). The clinical stage was T1a in five and T3b in two patients; in those with cT1a, thrombus was first identified with intraoperative ultrasonography in two and by palpation of the renal vein or during the NSS in the remaining three. Renal surface hypothermia was applied in four cases (mean 77 min) and warm ischaemia in three (mean 38 min). The mean (range) tumour size was 3.9 (2.5-6) cm and all the tumours were clear cell RCC on histology, and all had negative surgical margins. The mean estimated glomerular filtration rate (eGFR) decreased by 24% after surgery. One patient developed new-onset renal failure (eGFR < 30 mL/min/1.73 m(2) ). Postoperative urine leak occurred in one patient successfully managed with a JJ stent. One patient developed a local recurrence with level III inferior vena caval (IVC) tumour thrombus 9 months after NSS and was managed with radical excision and IVC thrombectomy followed by postoperative dialysis. Six other patients were free of recurrence with no need for dialysis at a mean follow-up of 30 months. CONCLUSIONS: In selected patients with pathological stage T3b RCC and tumour thrombus confined to the renal vein, NSS is a feasible treatment option with acceptable oncological and renal functional outcomes.

Ice burn: protecting the flank during renal cryotherapy.

INTRODUCTION AND OBJECTIVES: Cryoablation is a viable minimally invasive strategy for the treatment of small renal masses. One of the most common postoperative complaints is pain or paresthesia at the cryoprobe insertion site. The use of a 14-gauge angiocatheter to insulate the flank during renal cryotherapy was investigated. MATERIALS AND METHODS: Six Yorkshire swine underwent laparoscopy-guided percutaneous cryoablation of the upper and lower poles of both kidneys with a 1.47 mm (17 gauge) cryoneedle. Treatment consisted of a double 10-minute freeze separated by a 5-minute active thaw. Trials were randomized to placement of the cryoneedle directly through the flank or through a 14-gauge angiocatheter as an insulating sheath. Temperatures were recorded adjacent to the cryoneedle at two depths in the flank with a Multi-Point Thermal Sensor. RESULTS: Twelve trials were completed each with a bare and sheathed cryoneedle. The coldest temperature observed was -26 degrees C for the bare cryoneedle and -21 degrees C for the sheathed cryoneedle. At the outer sensor, there was a 4.1 degrees C increase in mean temperature for freeze 1, and 6.2 degrees C increase in mean temperature for freeze 2 with sheath use. At the inner sensor, there was a 3.0 degrees C increase in mean temperature for freeze 1, and 9.4 degrees C increase in mean temperature for freeze 2 with sheath use. There was a trend toward statistical significance of sheath insulation at the outer (p = 0.07) and inner (p = 0.08) temperature sensors. CONCLUSIONS: A 14-gauge angiocatheter may provide some insulation and thereby might help protect against "ice burn" during renal cryotherapy.

In vitro, ex vivo and in vivo isotherms for renal cryotherapy.

PURPOSE: Preoperative planning for renal cryotherapy is based on isotherms established in gel. We replicated gel isotherms and correlated them with ex vivo and in vivo isotherms in a porcine model. MATERIALS AND METHODS: PERC-17 CryoProbes (1.7 mm) and IceRods (1.47 mm) underwent trials in gel, ex vivo and in vivo porcine kidneys. Temperatures were recorded at 13 predetermined locations with multipoint thermal sensors. RESULTS: At the cryoprobe temperatures were not significantly different along the probe in any medium for either system (p = 0.0947 to 0.9609). However, away from the probe ex vivo and in vivo trials showed warmer temperatures toward the cryoprobe tip for each system (p = 0.0003 to 0.2141). Mean +/- SE temperature 5 mm distal to the cryoprobe tip in vivo was 19.2C +/- 16.1C for CryoProbes and 27.3C +/- 11.2C for IceRods. Temperatures were consistently colder with CryoProbes than with IceRods in gel (p <0.00005), ex vivo (p <0.00005) and in vivo (p = 0.0014). At almost all sites temperatures were significantly colder in gel and in ex vivo kidney than in in vivo kidney for CryoProbes (p = 0.0107 and 0.0008, respectively) and for IceRods (each p <0.00005). CONCLUSIONS: Gel and ex vivo isotherms do not predict the in vivo pattern of freezing. Thus, they should not be used for preoperative planning. The cryoprobe should be passed 5 mm beyond the tumor border to achieve suitably cold temperatures. Multipoint thermal sensor probes are recommended to record actual temperature during renal cryotherapy.

Impact of pneumoperitoneum on renal cryotherapy.

PURPOSE: Pneumoperitoneum is known to decrease blood flow to the kidney during laparoscopy. We investigated if this change in blood flow would increase the size of the cryolesion. MATERIALS AND METHODS: Twelve Yorkshire swine underwent laparoscopy-guided percutaneous cryoablation of the upper and lower pole of each kidney at four randomized pneumoperitoneum pressures (10, 15, 20, and 25 mm Hg). Cryolesions were made with a 1.47-mm IceRod (Galil Medical, Plymouth Meeting, PA). Each site underwent two 10-minute freeze cycles separated by a 5-minute active thaw with pressurized helium gas. At the conclusion of each freeze cycle, the iceball volume was measured with intraoperative ultrasound. After completion of the four cryolesions, the kidneys were harvested, and the cryolesion surface area was calculated. The lesions were fixed in 10% buffered formalin and then excised with a 1-mm margin to obtain a volume measurement using fluid displacement. RESULTS: Iceball volume was 3.41, 2.85, 3.44, and 2.36 cm(3) for freeze cycle 1 (p = 0.16) and 3.67, 3.34, 4.88, 3.95 cm(3) for freeze cycle 2 (p = 0.20) at 10, 15, 20, and 25 mm Hg, respectively. Cryolesion volume by fluid displacement was 4.06, 3.77, 3.97, and 3.93 cm(3) (p = 0.86) and cryolesion surface area was 4.55, 4.38, 4.39, and 4.20 cm(2) (p = 0.71) at 10, 15, 20, and 25 mm Hg, respectively. CONCLUSIONS: In this study, pneumoperitoneum pressure between 10 and 25 mm Hg did not affect iceball size as measured by intraoperative ultrasound, cryolesion volume by fluid displacement, or cryolesion surface.

Preliminary study of virtual reality and model simulation for learning laparoscopic suturing skills.

PURPOSE: Repetitive practice of laparoscopic suturing and knot tying can facilitate surgeon proficiency in performing this reconstructive technique. We compared a silicone model and pelvic trainer to a virtual reality simulator in the learning of laparoscopic suturing and knot tying by laparoscopically naïve medical students, and evaluated the subsequent performance of porcine laparoscopic cystorrhaphy. MATERIALS AND METHODS: A total of 20 medical students underwent a 1-hour didactic session with video demonstration of laparoscopic suturing and knot tying by an expert laparoscopic surgeon. The students were randomized to a pelvic trainer (10) or virtual reality simulator (10) for a minimum of 2 hours of laparoscopic suturing and knot tying training. Within 1 week of the training session the medical students performed laparoscopic closure of a 2 cm cystotomy in a porcine model. Objective structured assessment of technical skills for laparoscopic cystorrhaphy was performed at the procedure by laparoscopic surgeons blinded to the medical student training format. A video of the procedure was evaluated with an objective structured assessment of technical skills by an expert laparoscopic surgeon blinded to medical student identity and training format. The medical students completed an evaluation questionnaire regarding the training format after the laparoscopic cystorrhaphy. RESULTS: All students were able to complete the laparoscopic cystorrhaphy. There was no difference between the pelvic trainer and virtual reality groups in mean +/- SD time to perform the porcine cystorrhaphy at 40 +/- 15 vs 41 +/- 10 minutes (p = 0.87) or the objective structured assessment of technical skills score of 8.8 +/- 2.3 vs 8.2 +/- 2.2 (p = 0.24), respectively. Bladder leak occurred in 3 (30%) of the pelvic trainer trained and 6 (60%) of the virtual reality trained medical student laparoscopic cystorrhaphy procedures (Fisher exact test p = 0.37). The only significant difference between the 2 groups was that 4 virtual reality trained medical students considered the training session too short compared to none of those trained on the pelvic trainer (p = 0.04). CONCLUSIONS: There is no significant difference between the pelvic trainer and virtual reality trained medical students in proficiency to perform laparoscopic cystorrhaphy in a pig model, although both groups require considerably more training before performing this procedure clinically. The pelvic trainer training may be more user-friendly for the novice surgeon to begin learning these challenging laparoscopic skills.

Preliminary evaluation of a genitourinary skills training curriculum for medical students.

PURPOSE: Basic urology training in medical school is considered important for many medical and surgical disciplines. We developed a 2-day intensive genitourinary skills training curriculum for medical students beginning their clinical clerkship training years and evaluated the initial experience with this program. MATERIALS AND METHODS: All 94 third-year medical students at the University of California, Irvine were required to participate in a 5.5-hour genitourinary examination skills training program. The teaching course included 1.5 hours of didactic lecture and video presentation with questions and answers, followed by 5, 45-minute hands-on stations including male Foley catheter placement, female Foley catheter placement, testicular examination and digital rectal examination training with a standardized patient, virtual reality cystourethroscopy and, lastly, a urologist led tutorial of abnormal genitourinary findings. The students completed questionnaires before and after the course concerning their experience. At the end of the course the students rated the usefulness of each part of the curriculum and evaluated the faculty. In addition, they were required to complete a multiple choice examination that included 4 genitourinary specific questions. RESULTS: All 94 medical students completed the genitourinary skills training course. Before the course less than 10% of students reported comfort with genitourinary skills, including testicular examination (5%), digital rectal examination (10%), male Foley catheter placement and female Foley catheter placement (2%). Following the course the comfort level improved in all parameters of digital rectal examination (100%) and testicular examination, male Foley catheter placement and female Foley catheter placement (98%). The students rated in the order of most to least useful training 1) standardized patient for testicular examination and digital rectal examination teaching, 2) male Foley catheter placement and female Foley catheter placement training, 3) didactic lecture, 4) tutorial of abnormal genitourinary examination findings and 5) virtual reality cystourethroscopy. On the examination questions following the course 80% to 98% of the class answered each urology content question correctly. CONCLUSIONS: An intensive skills training curriculum significantly improved medical student comfort and knowledge with regard to basic genitourinary skills including testicular examination, rectal examination, and Foley catheter placement in the male and female patient. Further followup will be performed to determine the application of these skills during clinical clerkship rotations.

Hemangioendothelioma of urinary bladder--report of rare case.

Although cavernous hemangiomas and a few cases of angiosarcoma in the urinary bladder have been described, only a single case of epithelioid hemangioendothelioma of the urinary bladder has been documented in English publications, to date. Therefore, the biologic properties of epithelioid hemangioendothelioma in this location are uncertain. We report the clinical and pathologic findings of a case of primary epithelioid hemangioendothelioma of the urinary bladder in a 17-years-old boy. The tumor was treated by transurethral resection.

Robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas.

PURPOSE: We report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome. MATERIALS AND METHODS: From August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue. RESULTS: The average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome. CONCLUSIONS: Our experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.

Laparoscopic radical cystectomy and extracorporeal urinary diversion: a single center experience of 48 cases with three years of follow-up.

OBJECTIVES: To report our experience with laparoscopic radical cystectomy and extracorporeal urinary diversion for high-grade muscle invasive bladder cancer in a consecutive series of 48 patients with 3 years of follow-up. METHODS: From June 1999 to April 2006, 48 patients (42 men and 6 women; mean age 59 years, range 24 to 80) with bladder cancer underwent laparoscopic radical cystectomy and bilateral pelvic lymph node dissection at our institution. Urinary diversion was done extracorporeally through the specimen extraction incision. RESULTS: The mean operating time was 310 minutes, and the mean blood loss was 456 mL. In 1 patient, conversion to open surgery was required because of severe hypercarbia. Three major complications were observed intraoperatively (rectal injury in 2 and external iliac vein injury in 1 patient). However, all these complications were managed laparoscopically, with completion of the procedure laparoscopically. The mean hospital stay was 10.2 days (range 7 to 25). One patient died in the postoperative period of severe lower respiratory tract infection and septicemia. Histologic examination showed organ-confined tumors (Stage pT1/pT2/pT3a) in 34 patients (71%) and extravesical disease (pT3b/pT4) in 14 (29%). Of the 48 patients, 12 (25%) had lymph node involvement. The mean number of nodes removed was 14 (range 4 to 24). At a mean follow-up period of 38 months (range 10 to 72), 35 patients were alive with no evidence of disease (disease-free survival rate 73%). CONCLUSIONS: The results of our study have shown that laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy. Extracorporeal urinary diversion through a small incision decreases the operating time, while maintaining the benefits of laparoscopic surgery. The 3-year oncologic efficacy was comparable to that of open radical cystectomy.

Radical cystectomy for bladder cancer: A single center experience.

UNLABELLED: We present the outcomes of a large series of patients treated with radical cystectomy and pelvic lymphadenectomy for transitional cell carcinoma of bladder. MATERIALS AND METHODS: A total of 502 patients underwent radical cystectomy (RC) for bladder cancer from 1992 till December 2006. Of these, 432 patients with primary transitional cell carcinoma of bladder underwent RC with bilateral pelvic lymphadenectomy with a curative intent. The clinical course, pathologic characteristics and long-term clinical outcomes were evaluated in this group of patients. RESULTS: The median follow-up was 62 months. There were 30 (6.9%) perioperative deaths and 111(25.7%) early complications. The recurrence-free survival (RFS) and overall survival (OAS) were 66% and 62% at five years and 62% and 40% respectively at 10 years. The RFS and OAS were significantly related to the pathological stage and lymph node status with increasing pathological stage and lymph node positivity associated with higher rate of recurrence and worse OAS (P < 0.001). A total of 145 patients (33.5%) developed bladder cancer recurrence. Of these, 40 (27.6%) developed local pelvic recurrence and 105 patients (72.4%) developed distant recurrence. The median time to local and distant recurrence was 12 and 16 months respectively. CONCLUSION: The clinical results reported from this large group of patients demonstrate that radical cystectomy provides good survival results for invasive bladder cancer patients with low incidence of pelvic recurrence.

Epitheloid hemangioendothelioma of urinary bladder.

Epitheloid hemangioendothelioma is an uncommon vascular neoplasm and has an unpredictable clinical behavior. It is characterized by round or spindle-shaped endothelial cells with cytoplasmic vacuolation. Most often, epitheloid hemangioendothelioma arise from the soft tissues of the upper and lower extremities and it has borderline malignant potential. We describe the first reported case of epitheloid hemangioendothelioma in the urinary bladder, which was treated by transurethral resection. The diagnosis was confirmed by immunohistochemistry.

First case series of robotic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and urinary diversion with the da Vinci S system.

One of the recent developments in the da Vinci robot surgical system is the introduction of a more ergonomic four-arm robot. We report our experience of robotic radical cystectomy (RRC) for bladder cancer using the four-arm da Vinci(®) S(TM) robot (Intuitive Surgical, Sunnyvale, CA, USA). Beginning September 2006, we performed robotic radical cystectomy and bilateral pelvic lymphadenectomy in six patients with muscle-invasive bladder cancer using da Vinci(®) S(TM) robot. Ileal conduit diversion was made in five patients, and sigmoid orthotopic neobladder in one patient. The operating surgeon used the fourth arm for various steps such as bladder retraction for defining vascular pedicles, separating cystoprostatectomy specimen off the rectum, and while performing urethroneovesicostomy. The mean operative time was 12, 148, 44, and 126 min for docking, cystectomy, lymphadenectomy, and urinary diversion, respectively. Median blood loss was 200 ml. Mean hospital stay was 9.2 days. Surgical margins were negative in all the patients. The mean number of nodes removed was 12 (4-19). Histopathology revealed transitional cell carcinoma in all the patients (pT2a-1, pT2b-3, pT3a-2). Robotic radical cystectomy is feasible with new four-arm da Vinci(®) S(TM) surgical system. The operating surgeon can use the fourth arm of the robot as a substitute for the second assistant during the procedure. However, a patient-side surgeon with adequate training in laparoscopic skills is mandatory.

Evaluation of laparoscopic radical cystectomy for loco-regionally advanced bladder cancer.

We studied the safety and feasibility of laparoscopic radical cystectomy (LRC) in patients with loco-regionally advanced bladder cancer and report the short-term oncological outcome. This study comprised a total of 13 patients (10 males, 3 females), who presented with myriad of symptoms and on imaging they were found to have radiologically evident advanced disease (6 pelvic lymphadenopathies, 10 extravesical tumor extensions, three prostate/seminal vesical invasions). In view of recalcitrant symptoms (hematuria, frequency and irritative voiding) all patients underwent LRC and bilateral modified pelvic lymphadenectomy with ileal conduit urinary diversion. Mean age of the patients was 56.3 years. Mean operative time was 310 min with an average blood loss of 556 ml. No major intra-operative complications were noted. One patient died in the post-operative period due to sepsis. Histopathology report revealed pT3b N0 in two patients; pT3b N1 in four; pT3b N2 in three; pT4a N0 in one, and pT4aN1 in three patients. Adjuvant chemotherapy was administered in nine patients. At mean follow up of 18 months (range 6-28), seven patients are alive and cancer-free, while two patients are alive with metastases. LRC provides an alternative approach for treatment of patients with loco-regionally advanced bladder cancer, who suffer from recurrent hematuria and severe irritative voiding symptoms, in whom open surgery was the standard approach hitherto. However, it should be considered experimental and should be attempted only by surgeons who have significant experience of laparoscopic pelvic surgery and advanced skills, and after discussing the potential risks and benefits with the patient.

Prognostic significance of Her2/neu overexpression in patients with muscle invasive urinary bladder cancer treated with radical cystectomy.

INTRODUCTION: The aim of the study was to evaluate the status of Her2/neu protein expression in patients with muscle-invasive urothelial carcinomas of the bladder treated with radical cystectomy and to determine its prognostic significance. MATERIAL AND METHODS: We retrospectively analyzed the data of 90 patients who had undergone cystectomy for invasive transitional cell carcinoma of the urinary bladder. Immunohistochemical analysis for Her2/neu was done on paraffin-fixed tissues with CB11 antibodies (BioGenex, San Ramon, CA, USA). Sections with grade 2 and grade 3 staining were considered positive for Her2/neu. RESULTS: Over a median follow-up period of 46 months (24-96 months) 46 patients are living without disease recurrence and six with recurrent disease either at the local site or with distant metastases. The remaining 38 patients have died. The median overall survival time was 50 months, and median disease-free survival time was 40 months. The Her2/neu status was significantly related to the tumor stage (P = 0.001), lymph node involvement (77% in N+ vs 23% in N0; P = 0.001) and the grade of the disease (32% of grade 2 vs 71% of grade 3; P = 0.037). Kaplan-Meier curves showed a significantly worse disease-related survival period (log rank P = 0.011) for patients with Her2 overexpressing tumors than for those without overexpression. In addition to tumor stage [P = 0.001; relative risk (RR) = 2.62] and lymph node status (P = 0.0001; RR = 2.95), Her2 status (P = 0.020; RR = 2.22) was identified as an independent predictor for disease-related survival in a multivariate analysis. CONCLUSION: These results suggest that Her2 expression might provide additional prognostic information for patients with muscle-invasive bladder cancer. Future studies on Her2 expression with chemosensitivity and the efficacy of Her2-targeted therapies in urothelial carcinomas are warranted.