Andrew J Bernstein

Pelvic Lymphadenectomy During Robot-assisted Radical Prostatectomy: Assessing Nodal Yield, Perioperative Outcomes, and Complications

OBJECTIVES To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. METHODS PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score > or =4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. RESULTS The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. CONCLUSIONS Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered.

Urinary and Sexual Quality of Life 1 Year Following Robotic Assisted Laparoscopic Radical Prostatectomy

PURPOSE We evaluated urinary and sexual quality of life 1 year following robotic laparoscopic radical prostatectomy and identified preoperative variables predictive of a severe decrease from baseline. MATERIALS AND METHODS Using a prospective robotic laparoscopic radical prostatectomy database we identified patients with greater than 1 year of postoperative followup. The UCLA-PCI SF-36v2 questionnaire was used to evaluate urinary and sexual quality of life before and 1 year after surgery. Severe worsening of the postoperative score was defined as a greater than 1 SD decrease. Demographic and preoperative clinical variables were evaluated along with baseline scores on univariate and multivariate analysis. RESULTS Between February 2003 and September 2007 a total of 1,225 robotic laparoscopic radical prostatectomies were performed at our center and 361 patients (52%) met inclusion criteria. On multivariate analysis baseline urinary function was the only predictor of significant worsening of urinary function (OR 1.04, p = 0.003). Baseline urinary bother was the only predictor of significant worsening of urinary bother (OR 1.05, p <0.0001). A significant decrease in sexual function was predicted by baseline sexual function (OR 1.03, p = 0.0001), baseline sexual bother (OR 1.03, p = 0.005) and nerve sparing technique (OR 0.31, p = 0.05). Predictors of a significant decrease in sexual bother were also baseline sexual function (OR 1.02, p = 0.0001), baseline sexual bother (OR 1.04, p = 0.0007) and nerve sparing technique (OR 0.38, p = 0.02). ORs indicated that higher baseline scores corresponded to a higher risk of postoperative score worsening. CONCLUSIONS We found that overall better baseline sexual and urinary scores are associated with better postoperative outcomes. However, the risk of a significant decrease in urinary function, urinary bother, sexual function and sexual bother is higher in patients with better baseline scores. Nerve sparing positively affects sexual function and sexual bother.

Long-Term Functional and Oncological Outcomes of Patients Undergoing Sural Nerve Interposition Grafting during Robot-Assisted Laparoscopic Radical Prostatectomy

PURPOSE For men with high-volume or high-grade prostate cancer, wide excision of the ipsilateral neurovascular bundle is commonly performed. The concept of nerve reconstruction is intriguing as a feasible approach to preserve sexual function (SF). We sought to evaluate the functional, pathologic, and oncologic outcomes of men who underwent robot-assisted sural-nerve graft (SNG) interposition. PATIENTS AND METHODS Between February 2003 and May 2007, 1175 consecutive men underwent robot-assisted laparoscopic radical prostatectomy (RLRP). Database analysis identified 27 men who had SNG: 4 bilateral (BL) and 23 unilateral (UL). SF was prospectively evaluated preoperatively and at 1, 3, 6, 12, and 24 months postoperatively using validated questionnaires. Positive surgical margins (PSMs), biochemical recurrence (BCR), and potency were evaluated. RESULTS Compared with RLRP patients without SNG, patients with SNG were younger (57.2 v 61.8 years, P=0.02), had a higher Gleason score (P=0.02), and had a higher clinical and pathologic stage (P<0.001 for both). Mean surgical time was significantly longer (349 v 195 min, P<0.001) in patients with SNG. With a mean follow-up of 26.1 months, 11 (47.8%) patients with UL-SNG and zero men with BL-SNG regained potency. No significant difference in SF was observed between UL nerve sparing and no SNG (56%) compared with UL nerve sparing with UL-SNG (P=0.44). Rates of return-to-baseline SF (RTB-SF) at 6, 12, and 24 months were 11%, 36% and 45% for UL-SNG, respectively, which were also comparable to UL nerve sparing only (P>0.05). No patient (0%) in the BL-SNG group ever achieved RTB-SF status at any time point. PSMs were observed in 37% (10/27) of all patients. BCR occurred in nine patients (33.3%), seven of whom had PSM (78%); treatment failure occurred within 6 months of surgery, necessitating androgen deprivation therapy. CONCLUSION Despite optimism regarding SNG, long-term functional outcomes have been disappointing, particularly for BL nerve interposition. UL-SNG functional outcomes do not appear to improve outcomes when compared with men with UL nerve preservation. With the greater risk of PSM and BCR in patients who are considered candidates for SNG, newer treatment modalities are needed to cure their disease while preserving SF.

Impact of Renal Lesion Size on Perioperative and Pathologic Outcomes in Patients Undergoing Laparoscopic Partial Nephrectomy

BACKGROUND AND PURPOSE The size of renal lesions managed with laparoscopic partial nephrectomy (LPN) has been increasing, especially as surgical volume and experience matures. The objective of this study was to assess the perioperative and pathologic outcomes of LPN when stratifying for size of renal lesion. PATIENTS AND METHODS A retrospective review of LPN performed at the University of Chicago by a single surgeon (ALS) between October 2002 to July 2007 was performed. Patients (153) were then stratified into three groups according to radiographic diameter of the lesion: < or = 2 cm (group A), 2 to 4 cm (group B), and > or = 4 cm (group C). Perioperative, operative, and pathologic data were compared using analysis of variance and Pearson test. Moreover, serum creatinine and creatinine clearance (Cockcroft-Gault) were assessed postoperatively. RESULTS With regard to operative parameters, operative time was significantly longer in renal lesions > 2 cm (P = 0.0012), and the need for collecting system repair was also more prevalent as lesion size increased (P < 0.0001). Warm ischemia time was longest with lesions 2 to 4 cm (35.3 min) compared with masses < or = 2 cm (27.2 min; P < 0.001) or > or = 4 cm (30.3 min; P = 0.028). All other variables were similar among the three groups, including the rates of positive surgical margins, complications, estimated blood loss, conversion, and transfusion. Comparison of pathologic data suggests smaller lesions are more likely to be of lower grade compared with larger lesions. Postoperative renal function did not differ among the groups with a mean follow-up of 19.9 months. CONCLUSIONS Although LPN for renal masses 2 to 4 cm necessitated longer warm ischemia, short-term postoperative renal function was not affected by lesion size. Differences in warm ischemia time cannot be attributed solely to lesion size but are likely influenced by a combination of tumor size, location, and depth. LPN can be performed safely in selected patients with larger renal lesions.

Fifteen-Year Follow-up of Transplantation of a Cadaveric Polycystic Kidney: A Case Report

INTRODUCTION Kidneys from donors affected by autosomal-dominant polycystic kidney disease (ADPKD) are in general considered unsuitable for transplantation. To the best of our knowledge, only 12 cases of ADPKD transplanted renal units have been reported in the English literature; most have only short-term follow-up. METHODS We provide a review of these patients and share our experience with an ADPKD patient who received a 21-year-old deceased donor ADPKD-affected renal transplant and has been closely followed for 15 years. Based on the current literature, this report is the longest follow-up of a ADPKD donor transplant. RESULTS Over the 15-year follow-up period, there have been no complications related to the ADPKD-affected donor kidney, including three kidney transplant biopsies. The graft continues to function well with the serum creatinine currently 1.2 mg/dL. Serial axial imaging has demonstrated that the cystic disease has slowly progressed in the donor renal unit, with the largest cyst having only increasing from 1.2 to 2.9 cm in diameter. Metachronous, bilateral laparoscopic nephrectomies of the native kidneys were performed owing to intractable pain from cystic enlargement. CONCLUSIONS Normal functioning deceased donor kidneys that show signs of early ADPKD should be considered acceptable for donation in select cases. These organs provide the recipient a safe, reasonable period of graft survival and have not been shown to cause adverse effects.

ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY AFTER TURP: A MULTI-INSTITUTIONAL ANALYSIS OF ONCOLOGIC AND QUALITY OF LIFE OUTCOMES

1007 ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY AFTER TURP: A MULTI-INSTITUTIONAL ANALYSIS OF ONCOLOGIC AND QUALITY OF LIFE OUTCOMES Andrew J Bernstein, Daniel Eun, Mark H Katz*, Michael K Eng, Ronald S Boris, Sergey A Shikanov, Arieh L Shalhav, Gregory P Zagaja, James O Peabody, Kevin C Zorn, Mani Menon. Chicago, IL, and Detroit, M