Chris M. Teigland

Laparoscopic versus open nephrectomy in 210 consecutive patients: outcomes, cost, and changes in practice patterns.

Background: Initially slow to gain widespread acceptance within the urological community, laparoscopic nephrectomy is now becoming the standard of care in many centers. Our institution has seen a dramatic transformation in practice patterns and patient outcomes in the 2 years following the introduction of laparoscopic nephrectomy. We compare the experience with laparoscopic and open nephrectomy within a single medical center. Methods: Data were collected for all patients undergoing elective nephrectomy (live donor, radical, simple, partial, and nephroureterectomy) between August 1998 and September 2002. Data were analyzed by Wilcoxon rank sum, chi-square, and Fisher’s exact test. A p-value <0.05 was considered significant. Results: Of the patients, 92 underwent open nephrectomy, and 118 were treated laparoscopically (87 hand-assisted laparoscopic nephrectomy, 31 totally laparoscopic). There was one conversion (0.8%). Patient demographics and indications for surgery were equivalent for both groups. Mean operative time for laparoscopic nephrectomy (230 min) was longer than for open (187 min, p = 0.0001). Blood loss (97 ml vs 216 ml, p = 0.0001), length of stay (3.9 days vs 5.9 days, p = 0.0001), perioperative morbidity (14% vs 31%, p = 0.01), and wound complications (6.8% vs 27.1%, p = 0.0001) were all significantly less for laparoscopic nephrectomy. For live donors, time to convalescence was less (12 days vs 33 days, p = 0.02), but hospital charges were more for patients treated laparoscopically (

Surgical management of neurovascular bundle in uterine fibroid pseudocapsule.

19,007 vs

Detection and clearance of prostate cells subsequent to ultrasound-guided needle biopsy as determined by multiplex nested reverse transcription polymerase chain reaction assay

13,581, p = 0.0001). Conclusions: Laparoscopic nephrectomy results in less blood loss, fewer hospital days, fewer complications, and more rapid recovery than open surgery. We believe that these benefits outweigh the higher hospital charges associated with the laparoscopic approach.

Neurovascular bundle in fibroid pseudocapsule and its neuroendocrinologic implications

The authors propose that intracapsular myomectomy be recommended to maximize the potential for future fertility and to minimize the risk of labor dystocia or uterine rupture during pregnancy or labor.

Castleman disease of the hyaline-vascular type confined to the kidney

OBJECTIVES To determine if circulating prostate cells are detectable subsequent to transrectal ultrasound (TRUS)-guided biopsy, and if so, whether cells remain in circulation for up to 4 weeks. METHODS Blood samples were drawn from 90 patients with elevated serum prostate-specific antigen (PSA) levels and/or abnormal digital rectal examination. Two samples were drawn from all patients immediately prior to TRUS and 30 minutes postbiopsy. Blood samples were also obtained 1 week postbiopsy from 83 patients, and 1 month postbiopsy from 61 patients. Multiplex nested reverse transcription polymerase chain reaction assay (RT-PCR) for PSA and prostate-specific membrane antigen (PSM) was performed on total ribonucleic acid (RNA) from each sample. Results were reported as positive if at least one of the targets was detected. RESULTS Of 45 patients with biopsy-proven adenocarcinoma, 22 were RT-PCR positive prebiopsy and all remained positive 30 minutes postbiopsy. Of 23 patients with adenocarcinoma who were RT-PCR negative prebiopsy, 5 (22%) converted to positive 30 minutes postbiopsy (P < 0.001). Four of these 5 patients returned to negative after 1 week or 1 month. Of 45 patients without cancer at biopsy, 32 were RT-PCR negative prebiopsy and 6 (19%) converted to positive 30 minutes postbiopsy (P < 0.001). Although four of six available samples were still positive at 1 week, all four samples available 1 month postbiopsy were negative. CONCLUSIONS Detection of circulating prostate cells subsequent to biopsy occurred in 11 of 55 (20%) previously RT-PCR negative patients, a proportion twice that reported in the literature. We attribute this higher proportion to the simultaneous detection of PSA and PSM mRNA in our multiplex assay. Conversion rates were similar in patients regardless of biopsy result. Testing of serial postbiopsy blood demonstrates clearing of these cells by 4 weeks in most patients.

Active Surveillance of Very-low-risk Prostate Cancer in the Setting of Active Treatment of Benign Prostatic Hyperplasia With 5α-reductase Inhibitors

The myoma pseudocapsule is a surgical–anatomical entity surrounding the fibroid that separates the myoma from normal uterine tissue. The myoma pseudocapsule has a delicate vascular network rich with neurotransmitters analogous to the neurovascular bundle surrounding the prostate. The pseudocapsule neurovascular bundle is extremely important during myomectomy to promote uterine myometrial healing and, consequently, for uterine reproductive function. New advancements in surgery, including the use of laparoscopic myomectomy by an intracapsular technique and magnification of the myoma pseudocapsule to enhance visualization are comparable to the dissection during a radical prostatectomy. Fibroid detachment occurring inside the pseudocapsule causes less bleeding, spares the neurovascular bundle and promotes better uterine healing. The maintenance of myometrial integrity after laparoscopic myomectomy maintains uterine function and therefore improves reproductive outcomes, including labor.

Simultaneous detection of circulating prostate specific antigen (PSA)-expressing and prostate specific membrane antigen (PSM)-expressing cells by a multiplex reverse transcriptase polymerase chain reaction (RT-PCR) assay.

The case is a 38-year-old man in whom a solitary subcapsular left renal cortical mass was successfully resected. Comorbidities included a benign epididymal cyst and a history of nephrolithiasis. Computed tomographic imaging demonstrated a 1.8-cm enhancing mass in the anterior midregion of the kidney. An open partial nephrectomy was performed, and histopathologic examination established a diagnosis of the hyaline-vascular type of Castleman disease (CD). The patient had an uneventful postoperative course and has experienced no local or metastatic recurrence in the 10 months since surgery. CD localized in the kidney is an exceptionally rare occurrence but should be included in the complete differential diagnosis of solitary renal cortical mass lesions.

Two-step transurethral surgery of the prostate and permanent implant brachytherapy for patients with lower urinary tract symptoms and low- to intermediate-risk prostate cancer

OBJECTIVE To review the efficacy of treating benign prostatic hyperplasia and very-low-risk prostate cancer (PCa) in patients receiving active surveillance and 5α-reductase inhibitor (5-ARI; finasteride or dutasteride) treatment. MATERIALS AND METHODS Eighty-two men with very-low-risk PCa (clinical stage T1c, Gleason score ≤ 6, <3 biopsy cores positive with ≤ 50% involvement, and prostate-specific antigen density ≤ 0.15 ng/mL/g) and benign prostatic hyperplasia (≥ 30 cm(3)) received active surveillance and were treated with a 5-ARI. RESULTS All 82 men completed 1 year of 5-ARI therapy (n = 79) or underwent early biopsy for cause (n = 3). Restaging biopsies were performed for 76 men (22 underwent a second restaging biopsy and 1 a third restaging biopsy), 4 patients were awaiting biopsy, and 2 were lost to follow-up before the first restaging biopsy. At the first restaging biopsy, of the 76 men, 41 (54%) had no PCa, 16 (21%) continued to have very-low-risk PCa, 15 (20%) had progressed to low-risk PCa (>2 cores positive and Gleason score ≤ 6), and 4 (5%) had progressed to intermediate-risk PCa (Gleason score 7). Of the 76 biopsies, 20 were performed early for cause, with 11 (55%) showing PCa progression. Of the 82 patients, 22 (27%) underwent treatment of PCa. CONCLUSION Active surveillance of very-low-risk PCa in the setting of 5-ARI therapy for benign prostatic hyperplasia appears to be a safe therapeutic option, because most (57 of 82; 70%) patients maintained very-low-risk PCa or had negative follow-up biopsies during a 3-year follow-up period. Complementary to the Prostate Cancer Prevention Trial, our results indicate that 5-ARI therapy increases prostate-specific antigen sensitivity and can aid the clinician in appropriately targeting biopsies.

Duration and clinical significance of radiographically detected "free air" after laparoscopic nephrectomy.

It has yet to be determined whether the detection of prostate specific antigen (PSA)-expressing or prostate specific membrane antigen (PSM)-expressing cells in the circulation of prostate cancer patients is a more accurate predictor of clinical outcome. A method of evaluating both markers simultaneously would aid in the determination of the clinical relevance of reverse transcriptase polymerase chain reaction (RT-PCR) as a staging tool for prostate cancer. We describe the development of a multiplex RT-PCR assay that simultaneously detects the presence of both PSA-expressing cells and PSM-expressing cells, as well as a ubiquitously expressed internal control all within a single reaction. Both PSA cDNA and PSM cDNA were concurrently amplified by multiplex PCR using LNCaP mRNA as the starting template. When used as part of a nested PCR system, the multiplex RT-PCR assay identified one prostate cancer cell when placed in a background of one million cultured B lymphocytes. The multiplex assay was then applied to mRNA isolated from metastatic prostate cancer patients and from healthy male and female volunteers. While all were positive for the internal control G3PDH, three of seven prostate cancer patients were positive for both PSA and PSM expression and two more were positive for either PSA or PSM. None of the male or female volunteers were positive for either PSA or PSM. Multiplex RT-PCR allows for the amplification of both PSA and PSM cDNA within a single RT-PCR reaction, and this approach should allow a consistent comparison of the clinical utility of both PSA and PSM markers as staging tools and predictors of response to therapy.

Common Urologic Procedures

PURPOSE Prostate brachytherapy is an increasingly used treatment option for low- to intermediate-risk prostate cancer (PCa). However, patients with preexisting lower urinary tract symptoms (LUTS) and PCa, who would otherwise be good brachytherapy candidates, are often contraindicated because of the risk of postoperative urinary morbidity. We report our clinical experience with limited transurethral resection of the prostate (LTURP) and/or transurethral incision of the prostate (TUIP) months before brachytherapy to treat patients with LUTS and low- to intermediate-risk PCa. METHODS AND MATERIALS Of 258 men undergoing prostate brachytherapy at our institution between 1998 and 2011, 42 were treated with planned LTURP and/or TUIP well before (mean, 5.7 months) seed implantation. Transurethral surgery was considered before brachytherapy for patients who at presentation required α-blocker therapy for LUTS, had an International Prostate Symptom Score greater than 14 off α-blockers, or had an elevated postvoid residual (>100 mL). Patients only proceeded to brachytherapy once LUTS resolved. RESULTS All 42 patients in our series underwent TUIP (25), LTURP (7), or TUIP/LTURP (10) with mean 5.7 months before prostate brachytherapy for low- or intermediate-risk PCa. Mean International Prostate Symptom Score, peak flow rate, and postvoid residual significantly improved after transurethral surgery, and improvement persisted at the latest followup. No patient developed retention, urethral necrosis, or urinary incontinence after transurethral surgery or brachytherapy (median followup, 39 months and range, 1-121). CONCLUSIONS Planned LTURP and/or TUIP more than 4 months before brachytherapy is a safe and effective treatment strategy for men with LUTS and low- to intermediate-risk PCa.