Aaron D. Berger

Robotic Dismembered Pyeloplasty: A 6-Year, Multi-Institutional Experience

PURPOSE The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty. MATERIALS AND METHODS A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups. RESULTS Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts. CONCLUSIONS To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

A matched‐cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses

To compare the surgical outcomes of elderly patients with renal masses treated with laparoscopic partial nephrectomy (LPN) or laparoscopic cryoablation (LCA).

Transperitoneal Laparoscopic Radical Nephrectomy for Large (More Than 7 cm) Renal Masses

OBJECTIVES To evaluate our laparoscopic radical nephrectomy (LRN) series to determine whether any significant increases have occurred in operative morbidity when resecting large (7 cm or greater) renal masses. LRN is becoming the reference standard for treating suspicious renal masses not amenable to nephron-sparing surgery. METHODS We retrospectively reviewed the charts of 164 consecutive patients who had undergone laparoscopic radical nephrectomy performed for suspicious renal masses by two surgeons from February 2000 and December 2006. After institutional review board approval, we reviewed the patient charts to determine whether patients with 7-cm or larger lesions had significant differences in age, body mass index, American Society of Anesthesiologists class, operative time, estimated blood loss, conversion rate, positive margin rate, postoperative creatinine, and hematocrit compared with patients with lesions smaller than 7 cm. RESULTS The data from 164 patients were reviewed. Of these 164 patients, 124 had less than 7-cm masses and 40 had lesions 7 cm or larger. The mean tumor size in the less than 7-cm group was 4.2 cm (range 1.8 to 6.9) and was 9.2 cm (range 7 to 14) in the 7-cm or larger group. The patients with large tumors had a significantly longer operative time, greater estimated blood loss, and increase in postoperative serum creatinine than those with smaller tumors but all other perioperative variables were similar. Two conversions to open radical nephrectomy occurred in both groups. CONCLUSIONS Our data have clearly shown that larger tumors can safely be resected with transperitoneal laparoscopic nephrectomy. Open nephrectomy for large tumors can be associated with increased morbidity and the use of LRN could minimize this increased risk. Urologists with laparoscopic experience should consider expanding their indication for LRN.

Novel mutations of epidermal growth factor receptor in localized prostate cancer

We recently demonstrated that EGFR protein overexpression is more common in African American (AA) prostate cancer patients compared to Caucasian patients. We further examine EGFR dysregulation by determining EGFR mutation status in the tyrosine kinase (TK) domain in prostate cancer patients of different ethnicity. Normal and tumor DNA from 89 radical prostatectomy cases were studied for mutations in the EGFR TK domain using genomic DNA sequencing. We identified 4 novel missense mutations in exons 19, 20 and 21 of EGFR TK domain: 3 in Koreans and 1 in Caucasian but none in AA. We also identified 5 distinct synonymous DNA sequence changes, which did not alter the encoded amino acid, in exons 20 and 21 in 31/89 (35%) patients. Interestingly, these synonymous sequence changes were not observed in normal DNA in 7(23%) patients, indicating the presence of de novo somatic mutation to a new synonymous sequence. Our data reveal that EGFR missense mutation in the TK domain occurs in localized prostate cancer. Our data also demonstrate the presence of somatic mutation to a new synonymous sequence in a subset of patients. Larger population-based studies are required to define the association between EGFR mutations and the ethnic background of patients.

Bladder Neck Closure

Bladder neck closure (BNC) is a procedure that, although not performed frequently, can be very beneficial for an appropriately selected patient. T he t raditional role of BNC w as in the female patient with a neurogenic bladder, destroyed bladder neck, and patulous urethra from longterm indwelling catheter drainage (1, 2, 3, 4). Other options for urethral reconstruction using vagina or bowel have been reported, but are very complex, and attempts to create a patent and continent outlet are often unsuccessful (5). Other indications for the procedure have included bladder neck destruction from pelvic trauma, labor and delivery complications, and multiple failed surgical interventions to treat incontinence or urethrovaginal fistulas (6). Bladder neck closure can be combined with other procedures such as creation of a continent catheterizable stoma both separately or in combination with augmentation cystoplasty for patients with small capacity bladders or refractory detrusor overactivity (6, 7, 8). If the patient is unwilling or unable to perform intermittent catheterization, urinary drainage can be managed with a suprapubic tube or an ileovesicostomy (9). In early reports, BNC was often unsuccessful, but refinements in patient selection and surgical technique have significantly improved patient outcomes (13).