1,000 Retroperitoneoscopic Procedures of the Upper Urinary Tract: Analysis of Complications.

BACKGROUND AND OBJECTIVE: To evaluate risk factors and complications of retroperitoneoscopic procedures of upper urinary tract and adrenal gland. METHODS: From 1994 to 2016, 1,000 retroperitoneal laparoscopies were performed - 476 nephrectomies, 201 adrenalectomies, 103 partial nephrectomies, 91 pyeloplasties, 70 nephro-ureterectomies, and 59 miscellaneous surgeries (diverticulectomy). Data collection was prospective. We analyzed age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, operative time, blood loss, hospitalization stay and complications. Risks factors were explored with univariate and multivariate analysis. RESULTS: The mean BMI was 25 and median ASA 2. The mean operative time was 136 mn, mean blood loss 149 mL. There were 49 conversions. Of the patients, 41 required re-interventions, predominantly due to urinary fistula or post-operative bleeding. Post-operatively, 145 complications were recorded. In multivariate analysis, partial nephrectomies (OR 2.12, p = 0.031, 95% CI [1.07-4.22]) and pyeloplasties (OR 1.97, p = 0.02, 95% CI [1.11-3.48]) were significantly more at risk of complication than nephrectomies. An ASA score of 3 was also a significant risk factor of complications (OR 2.3, p = 0.014, 95% CI [1.17-4.47]) and an increased BMI carried a higher risk of conversion. There was no significant difference of conversion or complication rates between the first and last 500 patients. CONCLUSIONS: Upper urinary tract and adrenal surgeries can be performed by retroperitoneal laparoscopy. This surgical technic is safe and reproducible. The choice of the technic must be oriented by ASA, BMI and the type of surgery.

Kidney autotransplantation after nephrectomy and work bench surgery as an ultimate approach to nephron-sparing surgery.

BACKGROUND: Kidney autotransplantation (KAT) is the ultimate approach for nephron-sparing surgery. It is a rarely used method in renal tumor surgery today as minimal invasive and open techniques for nephron-sparing surgery improve constantly. In this publication, the complication rate and the long-term functional and oncological outcome at a single center are analyzed. METHODS: A prospectively constructed database of patients with renal tumors who underwent renal surgery was retrospectively analyzed to identify patients with KAT and describe surgical and oncological outcomes and to obtain long-term follow-up. Data collection included detailed surgical technique, complications (Clavian-Dindo), and hospital stay, as well as functional and oncological outcome and long-term follow-up. RESULTS: Between 1976 and 2013, 12 patients (median age 50.5 years) underwent KAT for highly complex renal masses: in five cases for complex renal cell carcinoma (RCC), five cases for complex upper urinary tract carcinoma (UTUC), one case for a renal metastasis, and one case for nephroblastoma. The nephrectomy or nephron-ureterectomy was performed open via a flank or transabdominal. The median surgical time was 360 min (range 270-490 min). Intraoperatively, six cases required blood transfusions (50%). Six patients (50%) developed significant postoperative complications (Clavian-Dindo > 2). In two patients, intermittent hemodialysis for delayed graft function (16.6%) was needed, and in six cases (50%), additional blood transfusions postoperatively were necessary. At discharge from hospital, all patients had functioning grafts. The median hospital stay was 29.5 days (range 18-35). At follow-up (median follow-up of 83.5 ± 40.7 months), six patients had died (50%)-all with functioning grafts (free from hemodialysis). In five cases, recurrence of primary tumor or metastatic disease was recorded. In four cases, the recurrent carcinoma could be resected; in detail, UTUC in three cases and one partial nephrectomy of the autotransplanted kidney was performed. One patient suffered from bone and lung metastasis. Two patients died finally tumor-related. Five patients (41.6%) are presently alive, without evidence of tumor relapse. One patient developed terminal renal failure requiring hemodialysis 105 months after autotransplantation. One additional patient was lost to follow-up; after 69 months, this patient had a functioning kidney and no evidence of disease-recurrence at the last follow-up. A cumulative number of 1424 months without hemodialysis was gained for these 12 patients. In the literature to date, most KAT are performed in benign disease, with minor but frequent complication. Here, we report the largest series of KAT for malignant kidney tumors. The complication rates are similar, compared to the recently reported series for benign indications with an improved graft survival rate. Since KAT requires a complex and challenging surgical approach, it should be performed by experienced kidney transplant surgeons. CONCLUSION: In very complex cases involving renal tumors and multi-morbidity, patients should be counseled well before KAT is considered. At the same time, KAT should not be abandoned in these very rare cases, especially when a nephron-sparing approach is otherwise not feasible. KAT can maintain renal function and quality of life and extend expectancy of life.

Update on 2-year outcomes of the TOMS™ transobturator male sling for the treatment of male stress urinary incontinence.

AIMS: To update the 2-year outcomes of the TOMS™ transobturator male sling for treating post-prostatectomy urinary incontinence (pRP-UI) in a group of patients previously evaluated at 1 year. METHODS: We prospectively followed 40 patients with pRP-UI before and 6, 12, and 24 months after implantation of the TOMS™ transobturator male sling. Urinary symptoms were evaluated using the following questionnaires: USP, ICIQ, UCLA-PCI (urinary bother domain), PGI-I, and daily pad use. Success was defined as patients wearing no or only one security pad. We also report on any other surgical procedures for treating persistent incontinence during the follow-up period. RESULTS: Of 40 patients included in the 1-year follow-up, seven required additional surgical treatment. In the remaining patients (n = 33), significant improvement (P < 0.001) compared to baseline was seen, and a subsequent tendency (non-significant) toward impairment was noted throughout the three postoperative follow-ups for the ICIQ (14.4 ± 4.4 [baseline], 7.6 ± 5.7 [6 months], 8.1 ± 5.6 [12 months], 8.9 ± 5.5 [24 months]), USP-stress urinary (6.7 ± 2.2, 2.8 ± 2.4, 2.8 ± 2.4, 3.2 ± 2.8), ULCA-PCI-urinary bother (10.0 ± 12.5, 66.0 ± 33.0, 64.0 ± 31.5, 62.0 ± 30.7) scores, and pad use (2.5 ± 1.2, 0.7 ± 1.1, 0.8 ± 1.2, 0.9 ± 1.2). Significant impairment in postoperative PGI-I (6.2 ± 0.9, 6.1 ± 0.9, 5.8 ± 1.1, P = 0.028) and USP-overactive bladder symptoms scores (5.4 ± 3.6 [6 months] vs. 6.6 ± 3.7 [24 months], P = 0.046) were noted. A total of 18 (54.5%), 17 (51.5%), and 15 (45.5%) patients wore no postoperative pad, respectively. CONCLUSION: Approximately half of the patients continue to wear no pad 2 years after TOMS™ transobturator male sling implantation. However, a tendency toward impaired continence, possibly associated with overactive bladder symptoms, was noted.

Adjustable continence therapy (ProACT™) after male sling failure for patients with post-radical prostatectomy urinary incontinence: a prospective study with one-year follow-up.

PURPOSE: To assess the effects of the ProACT™ device as a second-line treatment for persistent incontinence after male sling insertion. METHODS: Twenty consecutive patients were treated with the ProACT™ device due to persistent urinary incontinence following male sling insertion (9 AdVance™, 9 TOMS™, 2 InVance™). All balloons were implanted using a combination of fluoroscopic imaging and fibroscopic retrovision. Urinary symptoms were assessed prior to male sling insertion (T0) and before (T1) and 1 year after the ProACT™ insertion (T2) using questionnaires (ICIQ, USP, and ULCA-PCI-urinary bother) and by determining the number of pads used daily. RESULTS: The mean age of the study population at T1 was 68.6 ± 9 years. The mean volume of adjustment at T2 was 4.5 ± 2.7 mL. The previous sling did not cause any technical difficulties during ProACT™ insertion. Late wound infections occurred in the two patients who had been previously treated with the InVance sling and required removal of all implanted materials (Clavien-Dindo classification IIIb). Improvement in mean urinary scores was noted in the remaining patients (n = 18) through T0, T1, and T2, respectively: The ICIQ scores were 16.8 ± 2.6, 13.1 ± 3.4, and 5.7 ± 5.7 (P < 0.0001); USP stress urinary incontinence scores were 8 ± 1.8, 5.6 ± 2.2, and 2.4 ± 2.8, (P < 0.0001); USP overactive bladder symptom scores were 6.8 ± 4.3, 7.6 ± 4.3, and 4.1 ± 3.5 (P = 0.008), UCLA-PCI urinary bother scores were 7.1 ± 11.3, 28.6 ± 12.9, and 69.6 ± 31.6 (P < 0.0001), and number of pads used were 2.9 ± 1, 2 ± 1, and 0.3 ± 0.9 (P < 0.0001). USP obstructive symptoms were 0.4 ± 1, 1 ± 1.6, and 1.3 ± 1.4 (P = 0.19). CONCLUSIONS: The Pro-ACT™ device may provide additional benefits for improving continence in case of persistent incontinence following male sling insertion.

Quality of Preoperative Biopsy Is a Risk Factor for Positive Surgical Margins in Organ-Confined Prostate Cancer Treated with Nerve-Sparing Robot-Assisted Radical Prostatectomy.

PURPOSE: Positive surgical margins (PSM) during robot-assisted radical prostatectomy (RARP) negatively influence patients' prognosis. The aim of our study was to identify risk factors for PSM in patients with organ-confined prostate cancer (PCa). METHODS: A clinical database of all patients that underwent a RARP at our institution was used. Uni- and multivariable logistic regression analyses were conducted on the PSM rates for all patients with organ-confined PCa. RESULTS: Altogether, 1,600 patients were identified, including 1,085 organ-confined PCa with a PSM rate of 7.8%. On multivariable analysis, bilateral nerve-sparing (OR 3.025, 95% CI 1.587-5.765), surgeon volume <200 cases (OR 1.881, 95% CI 1.120-3.159) and a preoperative PSA >10 ng/ml (OR 3.674, 95% CI 1.379-9.796) remained independent prognostic factors. In a subgroup of patients undergoing a nerve-sparing RARP, the quality of the prostate biopsy (OR 2.398, 95% CI 1.325-4.341) was the sole independent risk factor for a PSM. CONCLUSION: An elevated preoperative PSA, surgical experience and a nerve-sparing procedure are all significantly associated with a higher risk for a PSM after RARP. For those undergoing a nerve sparing RARP, an accurate preoperative biopsy with detailed information on the location of positive cores is essential to prevent PSMs.

Robotic-assisted laparoscopic radical cystectomy: surgical and oncological outcomes.

PURPOSE: Our first 91 consecutive cases undergoing a robotic assisted cystectomy were analyzed regarding perioperative outcomes, pathological stages and surgical complications. MATERIALS AND METHODS: Between 2007 and 2010 a total of 91 patients (76 male and 15 female), 86 with clinically localized bladder cancer and 5 with non-urothelial tumors underwent a radical robotic assisted cystectomy. We analyzed the perioperative factors, length of hospital stay, pathological outcomes and complication rates. RESULTS: Mean age was 65.6 years (range 28 to 82). Among the 91 patients, 68 were submitted to an ileal conduit and 23 to a neobladder procedure for urinary diversion. Mean operating time was 412 min (range: 243-618 min) and mean blood loss was 294 mL (range: 50-2000 mL). In 29 % of the cases with urothelial carcinoma the T-stage was pT1 or less, 38 % were pT2; 26 % and 7 % were classified as pT3 and pT4, respectively. 14 % of cases had lymph node positive disease. Mean number of lymph nodes removed was 15 (range 4 to 33). Positive surgical margins occurred in 2 cases (2.1 %). Mean days to flatus were 2.13, bowel movement 2.88 and inpatient stay 18.8 (range: 10-33). There were 45 postoperative complications with 11 % major (Clavien grade 3 or higher). At a mean follow-up of 15 months 10 patients had disease recurrence and 6 died of the disease. CONCLUSIONS: Our experience demonstrates that robotic assisted radical cystectomies for the treatment of bladder cancers seems to be very promising regarding surgical and oncological outcomes.

A single center prospective study: prediction of postoperative general quality of life, potency and continence after radical retropubic prostatectomy.

PURPOSE: We investigated the importance of patient and tumor characteristics to predict continence, potency, and physical and mental health 1 year after radical prostatectomy. MATERIALS AND METHODS: This prospective study included 236 patients who underwent open radical retropubic prostatectomy at a single institution between January 2005 and October 2007. We used validated questionnaires, including the Short Form General Health Survey, the International Index of Erectile Function and the International Consultation of Incontinence Questionnaire, to evaluate postoperative health related quality of life, erectile function and continence, respectively. Questionnaires were completed at months 3, 6 and 12 postoperatively. RESULTS: At 1-year followup 75%, 73%, 75% and 26% of patients had returned to baseline physical health, mental health, continence and potency, respectively. Mental health recovered more slowly than physical health. Preoperative prostate specific antigen less than 20 ng/ml, nerve sparing technique, no intraoperative or postoperative complications, no adjuvant treatment and attendance at a postoperative rehabilitation program were significant factors that positively influenced the outcome in regard to health related quality of life, and postoperative potency and continence (p <0.05). CONCLUSIONS: Predictors can be used when counseling patients who are preparing themselves for radical retropubic prostatectomy. This study highlights the mental impact of this surgery on these patients. We propose that men should undergo a combined mental and physical counseling program before surgery to predict postoperative health related quality of life, potency and continence after radical retropubic prostatectomy.

Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year?

INTRODUCTION: Intracavernous alprostadil injection (IAI) is a widely used treatment for sexual rehabilitation (SR) after radical prostatectomy (RP). It is unknown whether the continuation of IAI beyond 1 year continues to improve erectile function. AIMS: To assess evolution of sexual function in patients using IAI who are nonresponsive to phosphodiesterase type 5 inhibitors (PDE5i) between 12 (M12) and 24 (M24) months after RP. METHODS: We retrospectively studied 75 men with a nerve-sparing laparoscopic RP, who had normal preoperative erectile function, and who regularly used IAI for SR for at least 24 months. At M12, no patients had responded to PDE5i. MAIN OUTCOME MEASURES: At 12 and 24 months, sexual function was assessed with the UCLA Prostate Cancer Index (UCLA-PCI), International Index of Erectile Function (IIEF)-15, and erection hardness score (EHS) with and without IAI. We also assessed the satisfaction rate with IAI, injection-related penile pain, and satisfaction of treatment. Statistical analysis was performed by using t-tests for paired data and Spearman's rho correlation coefficients to assess the relationships between scores at M12 and M24. RESULTS: Improvement of nocturnal erection was noted (UCLA-PCI, question 25); however, no significant difference was found for IIEF-erectile function with (19.60 ± 9.80 vs. 18.07 ± 10.44) and without IAI (4.63 ± 2.93 vs. 4.92 ± 4.15), UCLA-PCI-sexual bother (37.14 ± 21.45 vs. 37.54 ± 19.67), nor the EHS score with (2.97 ± 1.30 vs. 2.57 ± 1.30) and without IAI (0.67 ± 1.11 vs. 0.76 ± 0.10). The rate of satisfaction with treatment decreased over time (66.6% vs. 46.7%, P = 0.013). Improved response to IAI at M12 was not correlated to improvement in spontaneous erections at M24. CONCLUSION: The response to IAI remained stable after 2 years of treatment, and no significant improvement of spontaneous erections during intercourse attempts was found between M12 and M24. Patients should be informed of the limited effect of IAI on natural erections after 1 year. Yiou R, Bütow Z, Parisot J, Binhas M, Lingombet O, Augustin D, de la Taille A, and Audureau E. Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year? Sex Med 2015;3:42-48.

Highly sensitive and specific novel biomarkers for the diagnosis of transitional bladder carcinoma.

Transitional bladder carcinoma (BCa) is prevalent in developed countries, particularly among men. Given that these tumors frequently recur or progress, the early detection and subsequent monitoring of BCa at different stages is critical. Current BCa diagnostic biomarkers are not sufficiently sensitive for substituting or complementing invasive cystoscopy. Here, we sought to identify a robust set of urine biomarkers for BCa detection. Using a high-resolution, mass spectrometry-based, quantitative proteomics approach, we measured, compared and validated protein variations in 451 voided urine samples from healthy subjects, non-bladder cancer patients and patients with non-invasive and invasive BCa. We identified five robust biomarkers: Coronin-1A, Apolipoprotein A4, Semenogelin-2, Gamma synuclein and DJ-1/PARK7. In diagnosing Ta/T1 BCa, these biomarkers achieved an AUC of 0.92 and 0.98, respectively, using ELISA and western blot data (sensitivity, 79.2% and 93.9%; specificity, 100% and 96.7%, respectively). In diagnosing T2/T3 BCa, an AUC of 0.94 and 1.0 was attained (sensitivity, 86.4% and 100%; specificity, 100%) using the same methods. Thus, our multiplex biomarker panel offers unprecedented accuracy for the diagnosis of BCa patients and provides the prospect for a non-invasive way to detect bladder cancer.

Robotic-assisted laparoscopic radical cystectomy: surgical and oncological outcomes

PURPOSE:Our first 91 consecutive cases undergoing a robotic assisted cystectomy were analyzed regarding perioperative outcomes, pathological stages and surgical complications. MATERIALS AND METHODS: Between 2007 and 2010 a total of 91 patients (76 male and 15 female), 86 with clinically localized bladder cancer and 5 with non-urothelial tumors underwent a radical robotic assisted cystectomy. We analyzed the perioperative factors, length of hospital stay, pathological outcomes and complication rates. RESULTS: Mean age was 65.6 years (range 28 to 82). Among the 91 patients, 68 were submitted to an ileal conduit and 23 to a neobladder procedure for urinary diversion. Mean operating time was 412 min (range: 243-618 min.) and mean blood loss was 294 mL (range: 50-2000 mL). In 29% of the cases with urothelial carcinoma the T-stage was pT1 or less, 38% were pT2; 26% and 7% were classified as pT3 and pT4, respectively. 14% of cases had lymph node positive disease. Mean number of lymph nodes removed was 15 (range 4 to 33). Positive surgical margins occurred in 2 cases (2.1%). Mean days to flatus were 2.13, bowel movement 2.88 and inpatient stay 18.8 (range: 10-33). There were 45 postoperative complications with 11% major (Clavien grade 3 or higher). At a mean follow-up of 15 months 10 patients had disease recurrence and 6 died of the disease. CONCLUSIONS: Our experience demonstrates that robotic assisted radical cystectomies for the treatment of bladder cancers seems to be very promising regarding surgical and oncological outcomes.