Allan M. Shanberg

American cancer society–national prostate cancer detection project. Results from multiple examinations using transrectal ultrasound, digital rectal examination, and prostate specific antigen

Background. The American Cancer Society–National Prostate Cancer Detection Project is a prospective study of the feasibility of early prostate cancer detection by digital rectal examination (DRE), transrectal ultrasound (TRUS), and prostate specific antigen (PSA). Two thousand nine hundred ninety‐nine men not previously suspected of having prostate cancer have been entered on study in ten participating clinical centers.

Tension Pneumothorax Caused by the Argon Beam Coagulator During Laparoscopic Partial Nephrectomy

Pneumothorax is a well known complication of laparoscopic abdominal surgery. We report a case of tension pneumothorax caused by use of an argon beam coagulator in the retroperitoneal space during laparoscopic partial nephrectomy. CASE REPORT A 5-year-old female weighing 18.2 kg. had previously undergone bilateral ureteral implantation for vesicoureteral reflux with duplication of the left ureter. Subsequently obstruction of the ureter to the upper pole of the left kidney developed. Endoscopic dilation of the obstruction was unsuccessful and, thus, it was elected to perform laparoscopic partial nephrectomy of the upper pole of the left kidney for an atrophic segment. The patient was placed under general anesthesia with propofol and desflurane. Muscle relaxation was achieved with intermittent boluses of rocuronium. After intubation the child was placed in the right lateral decubitus position. Anesthesia was maintained with desflurane and meperidine. No nitrous oxide was used. The procedure was performed via a 10 mm. subcostal laparoscopic portal and 2 lower 5 mm. portals. The retroperitoneal space was hydrostatically dilated and carbon dioxide was introduced via the Hassan trocar. Carbon dioxide was insufflated at 3 l. per minute to a pressure of 12 cm. H 20. The argon beam coagulator was set on automatic, which delivers 3 to 12 l. gas flow per minute. The entire kidney was dissected free using sharp and blunt dissection. The branch renal artery and vein were then dissected on the posterior aspect of the kidney behind a large dilated upper pole ureter, and then clipped and transected. The ureter was transected and hemostasis was achieved. A harmonic scalpel was then used to amputate the upper third of the kidney. At various times diathermy or the argon beam coagulator were used to facilitate hemostasis. When the argon beam coagulator was used the trocars were opened to allow egress of argon gas to avoid increasing the retroperitoneal space pressure. The atrophic segment of kidney was removed uneventfully. There was no difficulty during any stage of the operation and no other organs were injured during the procedure. After removal of the upper renal pole oxidized regenerated cellulose was welded to the upper pole stump using the argon beam coagulator. Oxygen saturation immediately decreased from 100% to 80% and ventilator pressure increased to 35 cm. water. Both sides of the chest were auscultated and equal breath sounds were heard. Blood pressure then decreased from 100/55 to 75/40 mm. Hg, and the high pressure alarm on the carbon dioxide insufflator immediately sounded. As pneumothorax was suspected, the procedure was swiftly terminated and the patient was turned supine. Chest x-ray confirmed pneumothorax (see figure). A thoracostomy tube was rapidly placed. There was a gush of gas, and immediate resolution of the hypotension and hypoxemia followed. The surgery was completed uneventfully and the patient was extubated at the end of the procedure. The chest tube was removed the next day. Except for subcutaneous emphysema over the chest and face, the patient manifested no sequelae of this event. She was discharged home on postoperative day 3 and continues to do well. DISCUSSION

Followup Prostate Biopsy in Patients with Carcinoma of the Prostate Treated By 192Iridium Template Irradiation Plus Supplemental External Beam Radiation

We reviewed our experience with 81 patients who had undergone followup needle biopsies of the prostate between 12 and 27 months after 192iridium template radiotherapy combined with external beam radiation therapy. When broken down by stage 82% of the patients with stage A2, 92% with B1, 95% with B2 and 55% with C disease demonstrated a negative biopsy and adequate local control of the cancer. We believe that in elderly patients, poor risk patients with early stage disease and stage C lesions this low morbidity, low mortality therapy offers a viable option to other modalities of treatment.

Partial Transposition of the Penis and Scrotum with Anterior Urethral Diverticulum in a Child Born with the Caudal Regression Syndrome

Caudal regression is a rare anomaly often associated with urogenital abnormalities. We report a case of the caudal regression syndrome associated with partial transportion of the penis and scrotum, and a giant anterior urethral diverticulum. We also report our surgical technique for 1-stage reconstruction of the external genitalia, as well as a review of the embryological development of this anomaly.

1024: Immediate Impact of an Intensive One-Week Laparoscopy Training Program on Laparoscopic Skills Among Postgraduate Urologists

Introduction: Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience. Methods: Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of P≤0.05. Results: Between July 2003 and June 2005, 101 urologists participated in the M-R program. The mean participant age was 47 years (range, 31 to 70). The open surgical format had the highest ST scores followed by the robotic and then the laparoscopic formats. The final ST scores were significantly higher than the initial ST scores (P<0.05) for the laparoscopic (58 vs. 52) and the robotic (114 vs. 95) formats. Open surgical ST scores did not change significantly during the training program (191 vs. 194) (P=0.17). Conclusion: Laparoscopic and robotic ST scores, but not open ST scores, improved significantly during this intensive 5-day M-R program. The robotic ST scores demonstrated greater improvement than did the laparoscopic ST scores, suggesting that the transfer of laparoscopic skills may be improved using the robotic interface.

Endoscopic Use of Lasers in Pediatric Urology

Background: Advances in technology have made the urinary tract of small children more accessible to endourologic examination and intervention. Parallel advances in laser technology have complemented these developments, allowing ablative energy to be delivered through the small working ports of pediatric and infant cytoscopes. Patients and Methods: We report our experience with KTP laser treatment of posterior urethral valves (PUV) in 20 patients, ureteroceles in 9, and urethral strictures in 4. Results: All PUV ablations were successful, with no postoperative stricture formation. All ureterocele excisions were technically successful, although three patients subsequently required surgery for nonfunctioning upper poles, and one required ureteral reimplantation. All stricture incisions were unsuccessful, with open urethroplasty required by 2 years. An additional three patients, including one with a stone in a ureterocele, underwent holmium laser lithotripsy without complications and are stone free. Recently,...