Christopher M. Whelan

Robot-Assisted Laparoscopic Sacrocolpopexy as Management for Pelvic Organ Prolapse

BACKGROUND AND PURPOSE Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical management option for pelvic organ prolapse that secures the apex of the vagina to the sacral promontory. Limited literature exists on outcomes of this procedure. We present our initial experience with RALS. PATIENTS AND METHODS Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of 3 or greater were offered RALS without any other procedure. Chart review was performed to analyze operative and perioperative data, including urodynamics (UDS) and Baden-Walker classification before and after surgery. Data were analyzed with comparison of presurgical and postsurgical data. RESULTS From July 2005 through July 2007, 21 patients underwent RALS. Blood loss was negligible. Average operative time, including robot docking, was 3 hours, 14 minutes. Nineteen patients were discharged on postoperative day 1. UDS were not changed significantly. One patient had an apical recurrence. There were no operative complications or conversions; however, one patient had a small bowel obstruction 5 days after surgery necessitating laparotomy. Of the 21 patients, 12 have undergone anterior and posterior repair, 5 await repair, and 4 patients have opted for conservative management. CONCLUSIONS RALS is effective to repair apical vaginal defects in patients with significant pelvic organ prolapse. Operative time is manageable and complications are few. Cystocele, rectocele, and UDS remain essentially unchanged by RALS. Most, if not all, patients with cystocele and rectocele will need further vaginal reconstruction after RALS, if desired. Greater follow-up and numbers are needed to further establish the role of this procedure.

Differential Use of Partial Nephrectomy for Intermediate and High Complexity Tumors May Explain Variability in Reported Utilization Rates

PURPOSE Partial nephrectomy has become a reference standard for tumors amenable to a kidney sparing approach but reported utilization rates vary widely. The R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar tumor touching main renal artery or vein) nephrometry score was developed to standardize the reporting of tumor complexity with applicability in academic and community based settings. We hypothesized that tumor and surgeon factors account for variable use of partial nephrectomy. MATERIALS AND METHODS Clinical and R.E.N.A.L. nephrometry score data were analyzed on 1,433 cases performed between 2004 and 2011 by a total of 19 surgeons with varying partial nephrectomy utilization rates (0% to 100%) who practiced at a total of 2 academic centers and 1 community based health system. RESULTS Partial nephrectomy use increased during the study period from 36% before 2007 to 73% for 2010 to 2012 (p <0.0001). Increasing proportions of intermediate and high R.E.N.A.L. nephrometry score tumors were treated with partial nephrectomy during this time (35% to 86% and 11% to 36%, respectively, p <0.0001). Partial nephrectomy use was stable for low complexity tumors at 91% overall. Individual surgeons performed partial nephrectomy for 0% to 100% of intermediate complexity and 0% to 45% of high complexity tumors. On multivariable analysis surgery year, tumor size, each R.E.N.A.L. nephrometry score component, surgeon and annual surgeon volume predicted partial vs radical nephrectomy (each p <0.05). On multivariable analysis several surgeon factors, including surgeon volume, setting, fellowship training, and proportional use of minimally invasive and robotic partial nephrectomy, were associated with higher partial nephrectomy use (each p <0.002). CONCLUSIONS Surgeon and tumor factors contribute significantly to the choice of partial nephrectomy. The significant variation in partial nephrectomy use by individual surgeons appears to be caused by differential treatment for intermediate and high complexity tumors. This may be due to surgical volume, training, setting and the use of minimally invasive techniques.

Investigative UrologyExpressed Prostatic Secretion Biomarkers Improve Stratification of NCCN Active Surveillance Candidates: Performance of Secretion Capacity and TMPRSS2:ERG Models

PURPOSE Active surveillance is a viable patient option for prostate cancer provided that a clinical determination of low risk and presumably organ confined disease can be made. To standardize risk stratification schemes the NCCN (National Comprehensive Cancer Network®) provides guidelines for the active surveillance option. We determined the effectiveness of expressed prostatic secretion biomarkers for detecting occult risk factors in NCCN active surveillance candidates. MATERIALS AND METHODS Expressed prostatic secretion specimens were obtained before robot-assisted radical prostatectomy. Secretion capacity biomarkers, including total RNA and expressed prostatic secretion specimen volume, were measured by standard techniques. RNA expression biomarkers, including TXNRD1 mRNA, prostate specific antigen mRNA, TMPRSS2:ERG fusion mRNA and PCA3 mRNA, were measured by quantitative reverse-transcription polymerase chain reaction. RESULTS Of the 528 patients from whom expressed prostatic secretions were collected 216 were eligible for active surveillance under NCCN guidelines. Variable selection on logistic regression identified 2 models, including one featuring types III and VI TMPRSS2:ERG variants, and one featuring 2 secretion capacity biomarkers. Of the 2 high performing models the secretion capacity model was most effective for detecting cases in this group that were up-staged or up-staged plus upgraded. It decreased the risk of up-staging in patients with a negative test almost eightfold and decreased the risk of up-staging plus upgrading about fivefold while doubling the prevalence of up-staging in the positive test group. CONCLUSIONS Noninvasive expressed prostatic secretion testing may improve patient acceptance of active surveillance by dramatically reducing the presence of occult risk factors among those eligible for active surveillance under NCCN guidelines.

Increasing the number of biopsy cores before renal cryoablation increases the diagnostic yield.

BACKGROUND AND PURPOSE Renal cryoablation has been established as a primary management option for many small renal masses. Biopsy is performed intraoperatively and typically consists of one core being taken. This method was used to reduce the potential for seeding tumor and to minimize bleeding, although there have been no reports of tumor formation caused by biopsy seeding and blood loss is minimal. It is also associated with a relatively high yield of nondiagnostic cores. As such, in March 2005, we began taking three biopsy cores rather than one in an attempt to decrease our nondiagnostic rate. MATERIALS AND METHODS Biopsy results were retrospectively reviewed for patients who underwent renal cryoablation by two surgeons between February 2001 and July 2007. Findings were stratified according to the number of cores taken, which was either one or three. Tests for significance were performed using the chi-square test to determine if there was a difference in the nondiagnostic rates and the cancer yield rates. RESULTS Results of 119 biopsies were reviewed. Of those, a single core was taken from 81 (68%) lesions. Of these, 49 (60%) were malignant and 14 (17%) were nondiagnostic. The remaining 38 (32%) had three cores taken. Twenty-seven (71%) of these were malignant and two (5%) was nondiagnostic. The P values for cancer yield rates and nondiagnostic rates were 0.248 and 0.030, respectively. CONCLUSIONS Using a three-core biopsy strategy resulted in an 11% increase in cancer yield and a 12% reduction in nondiagnostic rate. Decreasing the nondiagnostic rate may help in counseling patients at follow-up. Continued investigation is warranted and under way.

The Influence of Surgical Approach to the Renal Mass on Renal Function

The National Kidney Foundation estimates that 26 million Americans are living with chronic kidney disease (CKD). The high prevalence of obesity, heart disease, hypertension, and diabetes places millions more at risk for developing CKD. Although long-term sufficient renal function is routine in screened kidney donors, CKD is present in more than 30% of patients with a newly diagnosed renal mass and develops in most patients who undergo radical nephrectomy and a portion of those who undergo nephron-sparing approaches. Herein, the authors review the effect of the surgical approach on renal function for patients presenting with a renal mass.