Carl K. Gjertson

Use and Assessment of PSA in Prostate Cancer

Since the introduction of prostate-specific antigen (PSA) screening in the late 1980s, more prostate cancers have been detected, and at an earlier stage. As a consequence, the majority of prostate cancers are now detected years before the emergence of clinically evident disease, which usually represents locally advanced or metastatic cancer. PSA screening has remained controversial, because many of the prostate cancers detected are low grade and slow growing. With this long natural history and a median survival without treatment that often approaches at least 15 to 20 years, many clinicians and researchers have questioned if prostate cancer screening and treatment actually improves survival, as many patients will die with prostate cancer rather than of prostate cancer. In this review, the authors discuss the rationale for prostate cancer screening and present the current guidelines for the use of PSA.

Testicular Pain Following Laparoscopic Renal Surgery

PURPOSE We have observed that a significant number of patients experience testicular pain following laparoscopic renal surgery. Since January 2006 all men scheduled for laparoscopic renal or adrenal surgery were followed prospectively to determine the incidence and characteristics of this pain. MATERIALS AND METHODS All patients had a history and physical examination before surgery, during postoperative hospitalization and 4 weeks after surgery. Pain and tenderness were scored on a standard 10 point scale. Preoperative and postoperative data were collected prospectively. RESULTS A total of 64 male patients (68 sides) met the criteria for evaluation. Ipsilateral testicular pain developed in 14 patients (21%). All patients describing pain underwent donor or radical nephrectomy. Of the 20 patients who underwent donor nephrectomy 11 (55%) experienced pain and of the 15 treated with radical nephrectomy 3 (20%) experienced pain. The gonadal vein was preserved in 29 patients and of those patients 1 had testicular pain (3.4%). When the gonadal vein was ligated 13 of 39 patients (33%) experienced pain (OR 14, 95% CI 1.7-115, p = 0.003). Mean pain intensity was 4 (range 1 to 8) and improved in all patients. Pain ceased without any intervention at a median of 34 days after surgery (range 7 to 110). There were no differences in operative time or blood loss between patients with or without testicular pain. CONCLUSIONS Ipsilateral testicular pain can occur after laparoscopic renal surgery. The incidence is approximately 50% after donor nephrectomy but pain can also occur after radical nephrectomy. Preservation of the gonadal vein may be protective. We now warn all male patients scheduled for laparoscopic nephrectomy of the possibility of postoperative testicular pain.

Laparoscopic and Robotic-Assisted Laparoscopic Radical Prostatectomy

There have been significant advances in laparoscopic skills and instrumentation since Schuessler and colleagues performed the first laparoscopic radical prostatectomy (LRP) in 1991 (1). Only nine LRPs were performed between 1991 and 1995. However, the surgery was difficult, with long operating times, and the laparoscopic approach for the treatment of prostate cancer was believed to offer no advantage over open surgery. In 1998, Guillonneau and colleagues reported their initial experience with the surgery with early results of the transperitoneal approach comparable to contemporary series of open radical prostatectomy (2 ). Since then, a number of centers have performed the LRP in increasing numbers with early results comparable to open surgery. However, LRP has not gained widespread popularity among urologists, owing to its technical demands, long operating times, and long learning curves.

RANDOMIZED PROSPECTIVE EVALUATION OF THE EFFECT OF PATIENT POSITIONING ON SURGICAL OUTCOMES DURING LAPAROSCOPIC RENAL AND ADRENAL SURGERY

INTRODUCTION AND OBJECTIVES: We report a prospective comparison of operative table positioning (i.e. flexion or no flexion) and its effect on outcomes in laparoscopic renal and adrenal surgery. METHODS: 30 consecutive patients undergoing laparoscopic nephrectomy or adrenalectomy by a single surgeon (CPS) were randomized to surgery with (FL) or without (NF) a 45 degree flexion of the operative table. A single surgeon performed all operations with a transperitoneal pure laparoscopic or hand assisted approach. Operative parameters such as ease of bowel mobilization (BM), ease of renal hilar dissection (HD), and overall difficulty of dissection (DD) were recorded on a 10 point Likert scale. Operative (OT), estimated blood loss (EBL), post-operative pain and peri-operative complications were also recorded prospectively. RESULTS: There were 15 and 15 patients in the FL and NF groups respectively. There were no statistically significant differences in BM, HD, DD, OT, EBL, or post-operative pain. The two complications in the FL group which included testicular pain and a minor serosal injury during mobilization of the colon. This serosal injury was repaired laparoscopically without further sequelae. There was one trocar site infection in the NF group. CONCLUSIONS: Although flexion of the operative table during laparoscopic nephrectomy and adrenalectomy has become standard practice, the effects of such positioning on operative time, ease of exposure, post-operative pain and complications has not been previously defined. Our prospective comparison suggests that there is no benefit to table flexion during laparoscopic renal and adrenal surgery. Surgical exposure, dissection and outcomes do not appear to be affected by patient positioning in this series

Radiating Abdominal Pain and Hypertension

teriorly. These findings were most consistent with an adrenal mass with cystic components and old blood. Magnetic resonance imaging (MRI) with and without gadolinium also showed a large septated cystic mass arising from the adrenal gland and containing both bright and low T2 signal material (Figure 2). In fact, MRI revealed that in addition to the cystic areas, the mass had multiple sections of solid tumor with a considerable amount of solid tissue located inferiorly in a small loculated region. A complete blood count, serum electrolytes, and creatinine level were all normal; serum glucose was 155 mg/dL. Further biochemical testing showed a random serum cortisol of 13 g/dL (normal, 7-23 g/dL), serum aldosterone of 4 ng/dL (normal, 2-12 ng/dL), and plasma renin activity of 0.9 ng/mL/hr (normal, 0.9-4.0 ng/mL/hr). The fractionated