Cribriform Pattern of The Prostate Adenocarcinoma: Sensitivity of Multiparametric MRI.

BACKGROUND: The aim of this study was to investigate the diagnostic performance of mpMRI for detecting cribriform pattern prostate cancer. MATERIALS AND METHODS: This study retrospectively enrolled 33 patients who were reported cribriform pattern prostate cancer at final pathology. The localization, grade and volumetric properties of the dominant tumors and areas with cribriform pattern at the final pathological specimens were recorded and the diagnostic value of mpMRI was evaluated on the basis of the cribriform morphology detection rate. It was analyzed using Wilcoxon test, the Chi-square test and Fisher's Exact test. The significance level (P-value) was set at .05 in all statistical analyses. RESULTS: A total of 58 prostate cancer foci were (38 cribriform, 20 non-cribriform foci) identified on the final pathology. mpMRI identified 36 of the 38 cribriform morphology harboring tumor foci with a sensitivity of 94.7% (95% confidence interval 82.7-98.5%). In 17 of the 33 patients mpMRI detected single lesion and for these lesions; mpMRI identified cribriform morphology positive areas precisely in 15 patients with significantly low ADCmean and ADCmin values compared to the non-cribriform cancer areas within the primary index lesion (P < .001). For the remaining 16 patients with multiple lesions; all of the tumor foci that harboring cribriform morphology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were detected between the cribriform and non-cribriform pattern tumor foci within the primary index lesion. CONCLUSION: Cribiform pattern should be considered in single lesions with an area of lower ADC value on mpMRI.

One step nucleic acid amplification (OSNA) for detection of lymph node metastasis during robotic radical prostatectomy for prostate cancer: A pilot study.

INTRODUCTION: The OSNA technique is based on reverse transcription loop-mediated DNA amplification for the detection of cytokeratin 19 (CK19) messen-ger RNA (mRNA). The purpose of our paper, which represents the first study in the literature, is to test the accuracy of this method in the detection of lymph node metastases in patients undergoing robotic radical prostatectomy with lymph node dis-section. METHODS: Our cohort consisted of patients that have undergone robotic radical prostatectomy with extended lymph node dissec-tion. Lymph nodes were evaluated with imprint technique and then with frozen section examination. The remaining tissue was evaluated by OSNA method. Lymph nodes were defined as 'neg-ative' or 'positive' according to mRNA copy number. RESULTS: 7 patients and 25 lymph nodes were included in our cohort. Two patients were found negative with all pathology methods. In one patient the standard stains revealed a suspi-cious outcome but it was positive for micrometastasis with OSNA. In another patient the outcome was positive for standard stains and negative for OSNA. Finally, 2 patients were found positive for OSNA and negative for imprint methods. CONCLUSIONS: One Step Nucleic Acid Amplification (OSNA) method using CK19 seems to fail in detection of lymph node metastases in prostate cancer patients undergoing radical prostatectomy and lymph node dissection.

Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes?

Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.

A prospective comparative analysis of robot-assisted vs open simple prostatectomy for benign prostatic hyperplasia.

OBJECTIVE: To report the first prospective comparative analysis of robot-assisted (RASP) vs open simple prostatectomy (OSP) for large prostate glands. MATERIALS AND METHODS: We prospectively analysed 41 patients who underwent surgery for benign prostatic hyperplasia between 2014 and 2017 at one of two university institutions. Patients were grouped according to the procedure (OSP or RASP) and matched in terms of age, prostate volume, body mass index and prostate-specific antigen level. The two groups were followed prospectively for 3 months, and their postoperative and functional outcomes were compared. RESULTS: Six patients (40%) in the OSP and seven patients (27%) in the RASP arm of the study had preoperative urethral catheters as a result of relapsed urinary retention. The amount of blood loss during surgery was significantly lower in the RASP arm (539  vs 274 mL), but the operating time was significantly longer (134 vs 88 min). One patient in the RASP group experienced a Clavien-Dindo grade II complication, whereas in the OSP group, four patients experienced serious complications (27%); one patient had a bladder rupture (Grade III), one patient developed deep venous thrombosis (Grade II), and two patients required blood transfusions (one unit each; Grade II). Two patients (one from each group) experienced urinary retention after catheter removal that required a urethral catheter replacement. In the follow-up period, there were significant and similar improvements in International Prostate Symptom Scores, uroflowmetry results and post-void residual urine volume in both groups. CONCLUSION: The results showed that RASP provided similar functional outcomes to those of OSP, whilst maintaining a good (or even better) safety profile. Our results suggest that RASP is a viable, efficient and potentially superior alternative to the open procedure.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve).

PURPOSE: To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS: Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS: Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION: Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

Prevention of Urethral Retraction with Stay Sutures (PURS) During Robot-Assisted Radical Prostatectomy Improves Early Urinary Control: A Prospective Cohort Study.

OBJECTIVE: To evaluate early continence rates with a novel modified vesicourethral anastomosis technique based on prevention of urethral retraction using anastomosis sutures as stay sutures (PURS) during robot-assisted radical prostatectomy. MATERIALS AND METHODS: Sixty patients operated by a single surgeon were enrolled and data collected prospectively. This cohort was compared with another consecutive 60 patients operated with standard anastomosis. The new technique is based on preventing urethral retraction of the posterior urethra with two anastomosis sutures being used as stay sutures. The outcomes were prospectively followed and groups compared regarding early continence. International Consultation on Incontinence Questionnaire Short Form was used to assess incontinence and its impact on the quality of life. Pad use (yes or no pads) was evaluated as a more stringent criterion. RESULTS: Preoperative patient characteristics were similar between the two groups. Anastomosis was completed faster in PURS group (15.1 vs 18.5 min, p = 0.05). At postoperative week 1 and month 1, the severity and bother of incontinence were significantly less in the PURS group (12.7 vs 4.1 and 10.1 vs 2.6, p < 0.001). PURS cohort reported significantly superior pad-free rates at both postoperative month 1 (73% vs 35%, p < 0.0001) and month 3 (83% vs 53%, p = 0.0004). On multivariable analysis, younger age and the new anastomosis technique were two independent predictors to improve early continence. Four patients in modified anastomosis group (4/60) and 1 in standard anastomosis group (1/60) necessitated temporary urethral recatheterization because of urinary retention. CONCLUSION: We describe a simple and time-efficient modified urethrovesical anastomosis technique by using anastomosis sutures as stay sutures to prevent perineal retraction of the urethral stump. Our results demonstrated that the technique is an independent factor impacting early recovery of urinary continence. Future randomized controlled studies would be required to further test the reproducibility of this technique.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes.

BACKGROUND AND OBJECTIVES: "Trifecta" in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes. METHODS: This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant. RESULTS: A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient. CONCLUSIONS: Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Minimizing Ports During Robotic Partial Nephrectomy.

BACKGROUND AND OBJECTIVE: Robotic upper urinary tract surgery is in most of the cases performed utilizing a standard 5 port configuration. Fewer ports can potentially produce a less invasive operation. Taking in consideration the above we report a novel technique for robot assisted laparoscopic partial nephrectomy utilizing fewer ports and we test its feasibility and safety profile. METHODS: Data on 11 robot-assisted laparoscopic partial nephrectomies performed by using our technique from February 2015 through June 2015 were retrospectively analyzed. The robotic platform used was DaVinci Xi (Intuitive Surgical, Inc., Sunnyvale, California, USA) with a 3-arm setup. The AirSeal system (SurgiQuest, Milford, Connecticut, USA) was used as a port allowing simultaneous introduction of 2 instruments for the bedside surgeon, obviating the need for an additional (fourth) robotic arm. A long suction-and-irrigation device and atraumatic grasping forceps were used. Both instruments were introduced through the trocar of the AirSeal system, making simultaneous introduction and use possible. We preferred the long suction-and-irrigation device, because it minimizes collision of the instruments. RESULTS: Mean age and BMI of the patients were 55 ±14.6 y and 29.18 ± 6.85, respectively. Seven tumors were on the right side and 4 were on the left. The mean size of the tumors was 32.45 mm (± 11.31). Surgical time was 132.2 minutes (±37.17), with an estimated blood loss and ischemia time of 103.63 mL (±65.92) and 16.72 minutes (±9.52), respectively. One patient had postoperative bleeding that was resolved without transfusion. The median hospitalization period was 3.9 d (±0.53). Loss of intra-abdominal pressure was not observed, and pressure was stable at 10 mm Hg. CONCLUSION: The AirSeal System and its valveless trocar eliminated the need for an additional port placement in our series. The technique is feasible, safe, and reproducible; therefore, it may be implemented in selected cases of robot-assisted partial nephrectomies.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

BACKGROUND: The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. PATIENTS AND METHODS: Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. EXCLUSION CRITERIA: The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. RESULTS: (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) and at the end of surgery (0.29±0.05) as well. CONCLUSION: We did not demonstrate any significant mesenteric-splanchnic ischemia which could be detected by serum IMA levels during robotic radical prostatectomies performed under steep Trendelenburg position and when IAP is maintained in between 11-14 mmHg.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience.

OBJECTIVE: To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. MATERIALS AND METHODS: The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. RESULTS: Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. CONCLUSION: The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction.

INTRODUCTION: Robot-assisted bladder diverticulectomy (RABD) through a technique for easier identification of diverticulum along with concomitant management of bladder outlet obstruction (BOO) utilizing a combination of transurethral prostatectomy (TUR-P) and photoselective vaporization of prostate (PVP) is presented. MATERIALS AND METHODS: Between 2008 and 2015, 9 patients underwent RABD with concurrent treatment of BOO. Diverticula were identified by a technique of catheterizing the diverticulum and the bladder simultaneously and individually. RESULTS: Mean patient age was 62 ± 9.8 and prostate volume was 70 ± 26 ml. Mean time for endourological procedure was 77 ± 35, mean console and total operative times were 108 ± 38 and 186 ± 56 min, respectively. Mean estimated blood loss was 71 ± 37 ml. All diverticula were excised and BOO treated successfully. Bladder irrigation was not necessary in any patient. Mean hospitalization and catheter removal time was 5 ± 3 and 8 ± 3 days, respectively. No complications were observed. CONCLUSIONS: BOO is the main cause of acquired bladder diverticula and is largely due to benign prostatic hyperplasia. Concomitant performance of TUR-P and PVP along with RABD is feasible and safe. Individual catheterization of the diverticulum and bladder facilitates the identification of diverticulum even in the presence of multiple diverticula.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

ABSTRACT Background The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. Patients and Methods Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. Exclusion criteria The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. Results (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) ...

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection.

OBJECTIVE: To determine an accurate incidence of lymphocele formation and its sequela after robot-assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort. PATIENTS AND METHOD: Consecutive patients who underwent RARP and eLND and had a minimum follow-up of 3 months were included. All surgeries were performed by one surgeon via a transperitoneal approach, with patients uniformly receiving low-molecular-weight heparin. Patients were followed with serial ultrasonography (US) based on a predetermined schedule for lymphocele surveillance. Incidence and sequelae of lymphoceles were retrospectively assessed. RESULTS: In all, 521 patients were analysed. The mean (sd) follow-up was 33.5 (22.8) months. Lymphocele developed in 9% and became symptomatic in 2.5%. All except one were detected at the 1-month postoperative US; however, 76% regressed by the 3-month US. If lymphocele persisted at 3 months, 64% developed symptoms associated with infection and required drainage. Having diabetes mellitus was significantly associated with a higher risk of developing an infected lymphocele. Other symptoms related to lymphocele were rare. Comparisons of patient characteristics between patients with and without lymphoceles did not show any significant prognostic indicators to predict the occurrence of lymphocele in neither univariate nor multivariate analysis in the present cohort. CONCLUSION: The incidence of symptomatic lymphocele after transperitoneal RARP and eLND is rare. However, during follow-up, US imaging at 3 months after surgery appears advisable. If a lymphocele is detected at the 3-month follow-up US discussing percutaneous external drainage with the patient appears to be wise, as it may prevent the development of a symptomatic lymphocele in two-thirds of such patients.

Nonprosthetic Direct Inguinal Hernia Repair During Robotic Radical Prostatectomy.

OBJECTIVE: To report our experience with concomitant hernia repair during robot-assisted radical prostatectomy (RARP) with a nonprosthetic and tissue-based technique. METHODS: We conducted a retrospective review on 1005 consecutive patients who underwent RARP between the years 2005 and 2015. Twenty-nine patients, who underwent 37, concurrent, direct, inguinal hernia repairs, were identified (group 1) and compared to a match control group of 29 patients who underwent RARP without hernia repair (group 2). Cases were matched 1:1 for age, body-mass index, and pathologic stage. The reinforcement of the floor was achieved with a modified posterior wall darn repair. The repair consisted of suturing the lateral edge of the rectus abdominis muscle sheath to the ileopectineal ligament (Cooper's ligament) with continuous prolene loose suture. This technique provided a tissue-based repair and the final reinforcement of the floor was expected to ensue by the secondary fibrotic tissue development and maturing between the sutures. RESULTS: From a total of 1005 patients who underwent RARP, 29 (2.8%) were preoperatively identified with a primary, direct inguinal hernia and underwent concomitant inguinal herniorrhaphy. The operative time was 147 minutes for group 1 vs 143 minutes for group 2 (p = 0.8). Estimated blood loss was 175 mL for the group with the hernia repair vs 200 mL for the group without repair (p = 0.3). There were no Clavien-Dindo grade >1 complications observed in either of the groups. Mean follow-up period was 32.1 months for group 1 vs 33.3 for group 2 (p = 0.8). Importantly, no hernia recurrences were observed. CONCLUSIONS: Inguinal hernias represent an important surgical issue and may be repaired concurrently during radical prostatectomy to minimize the risks of postoperative complications. The concomitant repair of inguinal hernias during robotic radical prostatectomy utilizing a nonprosthetic is a safe and feasible alternative for primary direct hernia repair during prostatectomy.

Robot-Assisted Laparoscopic Seminal Vesicle Cystadenoma Excision.

BACKGROUND: Cystadenoma is an extremely rare benign tumor of the seminal vesicle. Diagnosis of these tumors and differential diagnosis from malignant ones may be challenging since most of the time symptoms do not occur. Management of these tumors remains debatable due to the limited data in the literature. We present the first robot-assisted laparoscopic excision of a cystadenoma of the seminal vesicle. CASE PRESENTATION: A 48-year-old man presented with diminished ejaculate volume and a 3.5 cm right seminal vesicle mass, which increased its size at 6 cm after the 3-month period. Transrectal ultrasound-guided biopsy revealed no malignancy. Robot-assisted laparoscopic excision of the tumor was performed. Port placement was the same as robot-assisted radical prostatectomy. Operative time and estimated blood loss were 240 minutes and 200 mL, respectively. Patient was discharged on postoperative day 3 without any complications. Final histopathologic examination revealed cystadenoma of the seminal vesicle. CONCLUSION: Surgical intervention may be considered when a cystadenoma of the seminal vesicle is diagnosed and symptoms or tumor growth occurs. Robot-assisted laparoscopic excision is an alternative in the management of these rare tumors.

The use of a laparoscopic bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy: a novel technique.

PURPOSE: To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated. RESULTS: Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity. CONCLUSIONS: The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy.

Optimal control of the dorsal venous complex (DVC) is a critical step in robot-assisted radical prostatectomy (RARP). If DVC is not controlled properly, bleeding may occur during the apical dissection. On the other hand, if it is controlled well, a bloodless field is attained and, thus, a precise apical dissection and urethral division is possible. Suture ligation is the most common technique used for dorsal vein control, while some authors recommend using an endovascular stapler. Recently, athermal division and selective suture ligation technique has been reported for DVC control. We describe a new technique: Use of a bulldog clamp to control the DVC during RARP. The control of the DVC with a bulldog clamp allows a bloodless field with precise apical dissection and provides preservation of maximum urethral length while avoiding sphincteral injury.

The impact of local anesthetic volume and concentration on pain during prostate biopsy: a prospective randomized trial.

PURPOSE: To evaluate the effect of equivalent doses of local anesthetic administered at different concentrations and volumes on pain scores in patients undergoing prostate biopsy. PATIENTS AND METHODS: This study was a single-center, randomized trial. A total of 120 patients were randomized into two groups with 60 patients in each group. In group 1, 2.5 mL of 2% lidocaine (low volume-high concentration) and in group 2, 5 mL of 1% lidocaine (high volume-low concentration) was injected just lateral to the junction between the prostate base and seminal vesicle on each side under ultrasonographic guidance. Patients were given an 11 point visual analog scale (VAS) to evaluate the level of pain encountered during transrectal ultrasonographic (TRUS) probe insertion, injection of the local anesthetic, and the biopsy procedure. RESULTS: In both groups, TRUS probe insertion was the most painful stage of the procedure. With regard to local anesthetic injection, the VAS pain score was significantly lower in group 1 (1.56 vs. 2.41, P=0.001). Concerning sampling of the prostate, group 1 had a significantly lower VAS pain score compared with group 2 (1.71 vs. 2.48, P=0.008). Neither major complications nor side effects related to local anesthetic absorption occurred in both groups. CONCLUSION: Low volume-high concentration lidocaine administration provides superior analgesia compared with high volume-low concentration lidocaine during transrectal biopsy of the prostate.

Anterior and posterior reconstruction technique and its impact on early return of continence after robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: Urinary incontinence is a significant cause of morbidity after robot-assisted radical prostatectomy (RARP). Several techniques have been developed to improve continence rates. In this study, we compared the continence rates of patients who underwent RARP with total reconstruction and without reconstruction. PATIENTS AND METHODS: Between March 2005 and September 2009, 245 patients underwent RARP at our institution. The initial 120 patients (control group) underwent standard RARP without reconstruction and the last 125 patients (reconstruction group) underwent a total reconstruction technique, which included an anterior and posterior reconstruction. Patients were followed for 1, 4, 12, 24, 36, and 52 weeks after the operation. Continence was defined with strict criteria-no usage of pads and no leakage of urine. RESULTS: In the reconstruction group, the continence rates at, 1, 4, 12, 24, 36, and 52 weeks postoperatively were 71%, 72%, 80%, 84%, 86%, and 91%, respectively; in the control group, the continence rates were 23%, 49%, 76%, 80%, 85%, and 88%, respectively. CONCLUSION: The overall continence rates were similar in both groups at 52 weeks of follow-up. Patients in the total reconstruction group, however, had higher early continence rates compared with patients in the control group. The total reconstruction procedure is an efficient way to achieve an early return to continence.